Instructions to complete the Authorization for the Disclosure of Protected Health Information Form

This form is available for download in different languages:

You can also pick up the form at these locations:

To avoid delays in the process of the release:

Once signed and completed, you can fax or email the authorization back to us.

By fax: 508-334-9717
By email: MedCtrMR@umassmemorial.org
You can take a pictures of the form (both sides) and attach them to the email.

Form Instructions

Check off any boxes relating to which facility/facilities you would like to release records.
- Please note, if you select UMass Memorial Medical Group, you must provide the physician’s name in the location. Most providers release their own records.
Fill out all the Patient Information
- Please note, you are not required to provide the Medical Record Number
Check off whether the request is to Request & Receive, Release the records to your address, or release the records and mail to the patient’s address provided in the Patient Information section.
Enter the name and all contact information to whom the records are being sent.
Check off the Purpose of the request.
Select the level of information you would like us to release: Abstract or Entire Visit Date
- Abstract: The records we release contain the most commonly requested information and is less expensive.
- Entire Visit Date: Includes any and all documentation for the visit date/range of dates you specify.
Under Specific Services, please make sure that you check off the types of documents you wish to receive.
Please be sure to check off any box in the Protected Under State or Federal Law section that may apply to your request.
Specify how you wish to receive your records, mail, email, portal (if your MyChart account is active) or fax.
- If you wish to receive your records via email, please make sure to provide your email address
Please physically sign and date the authorization.

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