Harrington Medical Records Request
If you feel that the information contained in your medical record is incorrect, please fill out the Request to Amend Protected Health Information Form.
Your medical record is the physical property of the UMass Memorial Health clinical entity where you received your care. You have the right to review the record and to obtain a copy.
When you are discharged from any UMass Memorial Health entity, your medical record still must be completed by all providers involved in your care prior to being copied and released to you. This process can take up to 30 days. When needed, information may be released to a physician or medical facility for any follow-up and continued care you receive.
If you wish to receive a copy of your medical records or have the records forwarded to another party, please complete the Authorization for the Disclosure of Protected Health Information Form below.
Authorization for the Disclosure of Protected Health Information (English)
Authorization for the Disclosure of Protected Health Information (Spanish)
Authorization for the Disclosure of Protected Health Information (Portuguese)
Authorization for the Disclosure of Protected Health Information (Albanian)
Authorization for the Disclosure of Protected Health Information (Vietnamese)
Authorization for the Disclosure of Protected Health Information (Arabic)
Please make sure that the authorization is filled out completely for your request to be complied with in a timely manner:
- The top right-hand corner must have the patient’s name, date of birth, address and telephone number.
- The top left-hand corner must have the entity that you are requesting records from. Please note, if you are selecting UMass Memorial Medical Group, you must provide the physician’s name in the location. Most providers release their own records.
- Mark with a check whether the request is to Receive or Release records.
- If the records are for yourself, you must check off the box for Self. Otherwise, please provide the name and all contact information to whom the records are being sent.
- Mark with a check the Purpose of the request.
- Please make sure to provide date(s) of service that you wish to have released.
- Under Specific Services, please mark with a check the the types of documents you wish to receive. If you are looking for any images, or test recordings, please add to the category other and specify what is being requested. The request will be forwarded to the appropriate department(s) for processing.
- In the Protected Under State or Federal Law section, mark with a check any of the boxes if relevant to your request. If your record contains any of this information, we will not be allowed to release.
- Specify how you wish to receive your records: US Postal Service, email, or fax.
- There is a fee for medical records, so we encourage patients to request their records via email or portal.
- If the records are voluminous (over 100 pages), they will be placed on a password protected CD.
- Verbal is only used for communications by providers and not for releasing of medical records. If you wish to receive your records via email, please make sure your email address is written.
- Sign and date the authorization.
- Send the completed to:
Attn: Medical Records
100 South Street
Southbridge, MA 01550
Fax number: 508-765-3147
Health care proxy agents: If you are requesting records as a HCP agent, the health care proxy must be invoked by a provider and must be made for continuing care purposes.
Deceased patients’ medical records: If you are requesting an autopsy or medical records of a deceased patient, you must submit an authorization along with one of the legal documents obtained through the Probate Court:
- Court appointment as Executor of Estate/ Letter of Authority for Personal Representative
- Court Appointment as Voluntary Administrator/ Attested copy of Voluntary Administration Statement
Harrington Hospital Medical Records: Contact the Harrington Hospital Medical Records Department at 508-765-3085
Radiology images: please follow up with the Radiology department of the facility the services were provided:
- Harrington: 508-765-3030
- HealthAlliance-Clinton: 978-466-2689
- Marlborough: 508-486-5600 and follow the prompts
- University Campus: 774-441-8406
- Memorial Campus: 508-334-6131
A fee for photocopies may apply per Massachusetts General Law, Chapter 111, Section 70.” Upon receipt of a signed Authorization Form, UMass Memorial will process the request within seven to 10 business days and send an invoice for payment of the copies. Please note: A request may take up to 30 days if you are requesting records over 10 years old.
If you have any questions, please contact the Health Information Management department directly:
- By telephone: 508-334-5700 and respond to the menu prompts to reach additional assistance
- By email: email@example.com