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617-730-0327, or mailed to:

617-730-0327, or mailed to:-2026

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The document is an authorization form for the release of medical records from Boston Children's Hospital. It outlines the process for patients or guardians to request the release of protected health information, including necessary details such as demographics, purpose of release, format, and specific information requested. The form also includes sections for consent regarding sensitive information and requires signatures from the patient or guardian.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Demographics section. Enter the Patient's Last Name, First Name, Middle Initial, Home Address, City, State, Zip Code, and contact numbers.
In the Authorization section, specify who will receive the medical records by entering their Name/Facility and contact details.
Select the Purpose of Release by checking the appropriate box for Medical Care, School or Camp, Insurance, Personal, or Legal Matter.
Choose the Format of Release by checking either CD, Paper, Fax (to MD Office only), Electronic or Other.
Indicate the Information Requested by specifying a Date Range and selecting from options like Entire Medical Record or Medical Record Abstract.
On Page 2, initial next to each type of information you authorize for release and provide your signature along with the date.

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