Massachusetts Medical Records Release Form 3
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Authorization for
Release of
Medical Record
Information

MRN#:
DOB:
Pt Name:
Gender:

To request release of medical information please complete and sign this form and return it to:
Medical Records Department
Children's Hospital Boston
300 Longwood Avenue
Boston MA 02115

You may submit this form by Fax to: 617-730-0329
If you need help completing this form, please contact the Medical Records
Services Department at 617-355-7546.

Patient Information
Patient Last Name

First Name

MI

Street Address

Apt#

City

State

Children’s MR#

Home Telephone

Date of Birth

Alternate Telephone

Zip

(
(

)
)

Children's Hospital has my permission to release information contained in the Medical Record of the above
named patient.
Information Requested (please be specific and enter date of service if known):

Restrictions and/or Exclusions (if any):

Purpose of Release:
Children's Hospital will provide the information requested above to the following party:
Name
Attention of

Te