Medical Record Release Form


Medical Record Release Form
You need your records ASAP!!
Please follow the instructions below carefully and completely!
Records are mailed within ten (10) business days from the date we receive this completed request form.
The first copy of a patient’s medical record is released free of charge. *A fee of 25 cents per page,
payable in advance, is charged for additional copies.
Questions? Please contact the Medical Records Department. Phone (781) 674-1202 • Fax (781) 674-1520
NOTE: IVF New England cannot release records sent to our practice from another doctor’s office.
Date _____________ Patient Name __________________________ Patient Signature_______________________________
Date of Birth _____/_____/_________
Social Security # ____________________________________________________
Partner/Spouse Name _________________________________ Signature ________________________________________
Date of Birth _____/_____/_________
Social Security # ____________________________________________________
Where shall we send your first medical record copy for which there is no fee? CHECK ONE BOX BELOW
WE RECOMMEND that you have your medical records sent to your address
and that you make any additional copies as needed for your other physicians.
c To my address below
c To my physician’s office below
Patient Address _____________________________________
Physician Name ________________________________
City _______________________________________________
Address ______________________________________
State _________ Zip Code ____________________________
City __________________________________________
Reason for Request _________________________________
State _________ Zip Code ________________________
Fax # _________________________________________
Check box(es) below to indicate the records you are requesting.
c All Records
Due to Federal healthcare privacy regulations,
infectious disease and genetic test results must
c Ultrasound c Semen Analysis c Progress Notes
be specifically requested and are not included in
c PGD Results
“All Records”.
Please check necessary boxes.
c Other (specify) __________________________________
c Patient infectious disease testing
c Partner/spouse infectious disease testing
One Forbes Road, Lexington, MA 02421
c Patient genetic testing
Medical Records Department (781) 674-1202
Fax (781) 674-1520
c Partner/spouse genetic testing
Form available online at
(Patient Resources)


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Parent category: Legal