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Massachusetts Medical Records Release Form 1

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This form is provided by Massachusetts Effective Office of Health and Human Services to authorize the disclosure or release of one person's protected health information.

Massachusetts Medical Records Release Form 1
Massachusetts Medical Records Release Form 1
The health-care provider listed in Section II may share the following information with the MassHealth DES to determine eligibility for MassHealth
benefits.
All medical records or other information about my treatment, hospitalization, and/or outpatient care for conditions including:
psychological/psychiatric impairments how impairments affect activities of daily living and ability to work
AIDS/HIV drug and alcohol use
other (please describe):
Check here if you do not want the health-care provider to share information about AIDS/HIV status.
Check here if you do not want the health-care provider to share information about drug or alcohol use.
SECTION I
Permission is given for the health-care provider listed in Section II to share the medical information listed in Section III about
with the MassHealth DES.
SECTION II
SECTION III
Please print the name of the health-care provider that may share medical information with the MassHealth DES.
Name of doctor, health center, or other health-care provider:
Street address:
City, state, zip:
Telephone number: ( )
MassHealth Disability Evaluation Service
MassHealth Medical Records Release Form
Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth
This MassHealth Medical Records Release Form is to get medical information from your health-care provider so that the MassHealth Disability
Evaluation Service (DES) can make a disability determination.
Please read the instructions carefully before you fill out this form. If you leave any sections of this form blank, this permission will not be valid, and
the health-care provider will not be able to share your information with the MassHealth DES. If the health-care provider does not share medical
information with the MassHealth DES, we will not be able to make a disability determination.
General instructions for filling out the Medical Records Release Form
You must follow these instructions when filling out the Medical Records Release Forms. The health-care providers will not send medical records to
the MassHealth DES if you do not fill out the forms the right way. We cannot make a disability determination without copies of medical records.
1. Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other health-care provider you listed in
the Disability Supplement.
2. All signatures must be in ink and must be originals. No copies or stamps of signatures are permitted.
3. Only one signature may appear on a line.
4. If this form is for a child under age 18, one parent or legal guardian must sign for the child.
MADS-MR (Rev. 05/10) (continued on back)
(Please print name of applicant or member.)
s
Massachusetts Medical Records Release Form 1
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