Medical Record Release Form printable pdf download

Medical Record Release Form

You need your records ASAP!!

Please follow the instructions below carefully and completely!

Records are mailed within ten (10) business days from the date we receive this completed request form.

The first copy of a patient’s medical record is released free of charge. *A fee of 25 cents per page,

payable in advance, is charged for additional copies.

Questions? Please contact the Medical Records Department. Phone (781) 674-1202 • Fax (781) 674-1520

NOTE: IVF New England cannot release records sent to our practice from another doctor’s office.

Date _____________ Patient Name __________________________ Patient Signature_______________________________

Date of Birth _____/_____/_________

Social Security # ____________________________________________________

YYYY

Partner/Spouse Name _________________________________ Signature ________________________________________

Date of Birth _____/_____/_________

Social Security # ____________________________________________________

YYYY

Where shall we send your first medical record copy for which there is no fee? CHECK ONE BOX BELOW

WE RECOMMEND that you have your medical records sent to your address

and that you make any additional copies as needed for your other physicians.

c To my address below

c To my physician’s office below

Patient Address _____________________________________

Physician Name ________________________________

City _______________________________________________

Address ______________________________________

State _________ Zip Code ____________________________

City __________________________________________

Reason for Request _________________________________

State _________ Zip Code ________________________

__________________________________________________

Fax # _________________________________________

Check box(es) below to indicate the records you are requesting.

c All Records

Due to Federal healthcare privacy regulations,

(ATTENTION!)

infectious disease and genetic test results must

c Ultrasound c Semen Analysis c Progress Notes

be specifically requested and are not included in

c PGD Results

“All Records”.

Please check necessary boxes.

c Other (specify) __________________________________

c Patient infectious disease testing

c Partner/spouse infectious disease testing

One Forbes Road, Lexington, MA 02421

c Patient genetic testing

Medical Records Department (781) 674-1202

Fax (781) 674-1520

c Partner/spouse genetic testing

Form available online at

(Patient Resources)

Medical Record Release Form

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