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Massachusetts Medical Records Release Form 2

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This form is provided by MIT Medical to authorize the disclosure or release of one person's protected health information.

Massachusetts Medical Records Release Form 2
Massachusetts Medical Records Release Form 2
Medical Record Service
77 Massachusetts Ave., E23-023
Cambridge, MA 02139-4307
Phone: 617-253-4906
Fax: 617-258-0884
Authorization for Release of
Protected Health Information (PHI)
— Medical Record
Important information about releasing patient medical records
MIT Medical recognizes the patient’s right to confidentiality of protected health information as set forth in federal and Massachusetts state
law. You should be aware of these guidelines when requesting medical records.
State and federal laws recognize the need for written authorization.
All releases based on this form are limited to records dated up to and including the date of the patient’s signature. A new authorization is
necessary for release of information on care provided after the date of the patient’s signature, unless you (the patient or personal
representative) state in the authorization to release future records of a specific test, specific clinic appointment, etc.
If the patient is 18 years or older
, the patient must sign the release unless:
1. the patient is incompetent,
2. the patient is disabled and cannot sign the form, or
3. the patient is deceased. (The surviving spouse or legal representative with legal proof must sign the authorization for release of the
deceased patient’s records.)
If the patient is 18 years or younger
, the patient must sign the release if:
1. the patient is an MIT student, regardless of age
2. the patient is 14 years or older and the records involve treatment for mental illness, alcoholism, drug dependence, or AIDS testing,
or
3. the patient’s records for release include an abortion procedure.
Anyone other than the patient who signs this authorization for release of records must state their relationship to the patient and
provide proof of legal authority to release the records.
Please read before completing the form on the next page:
o This form must be completed in its entirety and signed by the patient or personal representative to be a valid authorization. Incorrect
or incomplete forms will not be processed.
o The MIT Medical Records Service does not fax records. If you wish to have the information disclosed to you directly, you will be
charged a fee. The fee is $0.50 per page for the first 100 pages and $0.25 per page for each page thereafter. The fee may be paid
by cash, personal check, money order, Visa or MasterCard.
o There is no fee for records released directly to other healthcare providers.
o When copies of the medical record are requested for parties other than the patient, the recipient of the record will be charged a $15
base fee.
o If you wish to complete this form in person at MIT Medical, make sure to bring two forms of ID. One must be a government ID
(driver’s license, state ID, or passport). If you have any questions or need more information, please call the Medical Records
Correspondence Service at 617-253-4906.
o To obtain a copy of test results, procedure and/or notes that were done at another healthcare organization, please contact that
organization directly.
Massachusetts Medical Records Release Form 2
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