Medical Record Release form - Cambridge Health Alliance 2025

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The document is an authorization form for the release of medical records from Cambridge Health Alliance. It requires patient information, specifies the recipient of the records, and outlines the purpose and format of the disclosure. The form includes options for sensitive information and details about revocation rights. It must be signed by the patient or their representative.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is MRN on medical release form?

The Medical Record Number (MRN) is the critical link between a patient and the patients medical records. All UTMB Health staff responsible for patient registration must ensure that each patient receiving services at UTMB Health is assigned only one unique, permanent MRN.

Can I sue my doctor for not releasing my medical records?

If you believe that your doctor or other health care provider violated your health information privacy right by not giving you access to your medical record, you may file a HIPAA Privacy Rule Complaint with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights.

How to write an authorization to release medical records?

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.

How to fill out a release form?

Some of the crucial information in a release includes: Name of the parties involved, i.e., releasor and releasee. Detailed information about the project. Explicit information of the permissions granted. Any special considerations, including payment obligations or credit, if any. A space for all parties to sign.

How to fill out an authorization form?

A valid authorization must be written in plain language and contain the following elements: A description of the information to be used or disclosed. The identification of the person authorized to make the requested use or disclosure. The name of the person to whom the entity may make the requested use or disclosure.

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How to fill out authorization for release of medical records?

How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.

What information must be included on an authorization to release information?

Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.

What is the fax number for Cambridge Health Alliance medical records?

Medical records track your medical history and care Fax to CHA Health Information Management: 617-381-7179. Mail to CHA Medical Records - 103 Garland Street Everett, MA 02149.