Instructions for Requesting Medical Records

The Authorization for the Disclosure of Protected Health Information form is available for download in different languages: 

English  |  Spanish  |  Portuguese  |  Albanian  |  Vietnamese  |  Arabic 

You can also pick up the form at these locations:

• University Campus, 55 Lake Avenue North, Worcester
• HealthAlliance-Clinton Campus, 60 Hospital Road, Leominster

To avoid delays in the process of the release:

• Fill out the form completely
• Use clear handwriting

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.