Medical release form

A medical release form lets you get specific information in your family member's private medical records, directly from doctors.

It only lets you see the information and communicate with the doctor. It does not give you any say in decisions.

Here's what you can do:

  1. Talk about this with your family member, a lawyer, and other helpful people like teachers, case managers, or doctors.

  2. Download and fill out the medical release form from the Massachusetts Department of Public Health by clicking the link at the bottom of the page.

    • In Section I, write in the specific doctor or provider who will share the info.

    • In Section II, write in the specific info you want access to.

    • In Section III, write in the specific reason for the request. Your family member may simply write "at my request" here.

    • In Sections IV and V, specify who else, if anyone, the info can be shared with. You might list other providers or school officials here. Talk with the doctor and your family member to decide what is best.

    • In Section VI, specify the time limits on the request. Talk with the doctor and your family member to decide what is best.

    • In Section VII, your family member must sign the form to give consent.

  3. Make copies of the signed form for the doctor, your family member, and your own records.

 

Sources: MA Department of Public Health, MA Legal Assistance Corporation

 

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