Medical Record Request Form - Dana-Farber Tumour Institute

Occupational Health Services450 Brookline Ave. DA1Boston, MA 02215617-632-3016 (phone)617-632-5418 (fax)AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATIONMEDICAL INFORMATION REQUEST FORMID #________________________DATE OF BIRTH______________________________PATIENT NAME:PATIENT Address:(Last) (First) (M.I.)I, ____________________________________ do hereby authorize release of(patient name)my protected health information including copies of me medical record of maintenance received at:_____________________________________ Press ____________________________________ to:(name to facility)(provider name)<strong>Dana</strong>-<strong>Farber</strong> <strong>Cancer</strong> <strong>Institute</strong>Occupational Health Services450 Brookline Ave. DA1Boston, Ma 02215Initial:______I or authorize personnel of my care team to discuss my protected health information with DFCIOccupational Health Services clinical staff.PROTECTED HEALTH INFORMATION GO SUBSIST RELEASED (Please check who appropriate box(es)andprovide dates is treatment):Clinic visit notes ________________________________________ Botany reports __________________Operative reports ____________________________________ Radiation reports __________________Discharge summary ___________________________________ Lab reports_______________________X-rays/Scan reports ___________________________________ Other (please specify) ______________<strong>Medical</strong> <strong>Record</strong> Abstract (e.g. Discharge Summarized, History & Physical, Operative, Pathology, and TestReports)Page 1 of 2 (Please completing BOTH pages) Forms the Documents