Requesting a Copy of Your Medical Record Information

Atrius Health’s Release of Information Department has trained professionals who manage your health information and medical record.

Frequently asked questions and answers from patients requesting copies of medical records are listed below.

If you have any additional questions, please contact the Release of Information Department during our normal hours of operation.

Please note – Our office is not physically accessible to patients.

Mailing Address: Hours of Operation:

Release of Information Department Monday – Friday: 8:00AM – 4:00PM

Atrius Health

1177 Providence Hwy Telephone and Fax Numbers:

Norwood, MA 02062 Tel: 781-292-7700 Fax: 617-421-2626

FREQUENTLY ASKED QUESTIONS

Q. How do I obtain a copy of my medical records?

A. You may access and request records be sent to you via our secure patient portal, MyHealth. Your health information is

available 24/7 to view, download, print and request. Simply log into your MyHealth account and complete the Medical Record

Request form. Once processed, you will receive a notification that you have a New MyHealth message.

If you do not have a MyHealth account or are authorizing us to send records to a third-party, you may request your records in

writing by submitting the completed authorization form on the next page. A completed copy of our authorization form should

accompany this FAQ sheet, and can also be downloaded from our website https://www.atriushealth.org/patient-

information/access-your-medical-records. Your request should be mailed or faxed to the address above or emailed to

medicalrecords@atriushealth.org.Please note that should you email your request, we cannot guarantee your email will be secure.

 In most cases, patients 18 years or older must sign their own authorization unless a court has appointed the patient a legal guardian or

representative. Proof of legal authority/representation is required.

Requests for Billing information, Pharmacy records, and/or Radiology Images/Films must be made directly to each of those departments

Q. Is there a cost to obtain a copy of my medical records?

A. There is no charge for requests requested and delivered via MyHealth. Other requests are charged a reasonable cost-based fee

for producing and sending copies of medical records pursuant to HIPAA 45 CFR 164.524 and Massachusetts law. Often, an Abstract

is sufficient for most patient needs. An Abstract consists of your immunizations, problem list, past medical history, 3 years of

office/telehealth visits, lab and diagnostic test results. If you want your entire record or more than an Abstract mailed to you, the

rate may increase proportionately and will include postage costs for mailing.

Q. How can I submit my payment?

A. For requests for delivery other than via MyHealth, you will receive an invoice mailed from our copy service, Sharecare, shortly

after we receive and process your request. Payment must be received by Sharecare prior to the release of your records.

Q. How soon can I expect the release of my medical record to be completed?

A. Processing time varies depending on the type of request and method of delivery. Requests via MyHealth are usually prepared

and released within 3 business days. Other routine requests are usually prepared within 7 business days and released upon

receipt of payment. Please note there are instances where a request may take longer to process.

The following scenarios are the most common requiring additional time to process:

 Requests containing information under the ‘Information Requiring Specific Consent’ box of the authorization form where

the appropriate box was not initialed may take longer because we must redact the information needing specific consent.

 Requests for copies of Behavioral Health records that are being released directly to the patient take longer because we are

required by law to obtain clinician approval prior to releasing.

 Information prior to 2010 may be delayed because we may need to retrieve a paper chart from storage.

Authorization to Release Medical Records From Atrius Health

PATIENT INFORMATION

Full Name: ________________________________________________________ Date of Birth: __________________________

Street Address: ____________________________________________________ Phone Number: ________________________

City, State, Zip: __________________________________________________________________________________________

RECIPIENT INFORMATION

I hereby authorize Atrius Health to release copies of the medical records of the above-named patient, to the following person or facility:

Person/Facility Name: _______________________________________________ Phone Number: _______________________

Address: __________________________________________________________ Fax Number: _______________ __________

City, State, Zip: __________________________________________________________________________________________

PURPOSE

 Continuing Care (second opinion/specialist)  Personal  Transfer/Leaving  Other (specify): _____________________________

Please provide reason for transfer:

 Moved/moving – in-state  Moved/moving – out-of-state  Insurance is no longer accepted  Other (specify): _______________________

Fee Information

Pursuant to HIPAA 45 CFR 164.524 and state law, we reserve the right to charge a reasonable cost-based fee for producing and sending the copies.

Often times, an Abstract is sufficient for most patient care. If you want copies of the entire record or more than an Abstract, the rate may increase

proportionately and will include the cost of postage. At no time will the cost-based fees exceed Massachusetts law (MGL Chapter 111; Section 70).

Delivery Format (file size restrictions may apply for certain electronic formats)

Please check one – if nothing is checked, paper copies will be sent via mail 



 Secure Email*: _____________________________________________  Fax (to Recipient's fax above  Paper  CD

(*To the patient or parent/guardian only. Please print your email address clearly)  via USPS 



INFORMATION TO BE RELEASED

 Abstract (3 years of office/telehealth visits, lab and diagnostic test results)

*OR* CHECK AND COMPLETE BELOW

 Office Visits: Date range ____________ to ____________ Provider(s)/Specialties: ________________________________________________

 Lab results: Date range ____________ to ____________  Imaging/Procedure Reports: Date range ___________ to ____________  Immunizations

 Other (please specify):______________________________________________________________________________________

RELEASE OF INFORMATION REQUIRING SPECIFIC CONSENT

The following categories of information may be included in your medical record and WILL NOT be released unless you indicate your specific

authorization by INITIALING each appropriate category.

CATEGORY INITIALS CATEGORY INITIALS CATEGORY INITIALS

Abortion Behavioral Health HIV/AIDS Results/Treatment

Alcohol/Drug Abuse Genetic Testing Sexually Transmitted Diseases

Review and SIGN

I understand that I may refuse to sign this authorization. I understand that my refusal will not affect my ability to obtain treatment at Atrius Health.

I may revoke this authorization at any time by submitting a written notice of revocation to Atrius Health at the address listed above. The revocation

will be effective upon Atrius Health’s receipt of my written notice, except that it will not have any effect on any action already taken by Atrius Health

in reliance on this authorization. Once Atrius Health has disclosed my health information to the recipient, I understand that Atrius Health cannot

control how the recipient uses or rediscloses my health information and the information may no longer be protected by federal or state privacy laws.

This authorization will automatically expire 90 days from the date of my signature below unless otherwise specified: ________________________

___________________________________________________ ________________________________________________

Signature of Patient or Legal Representative Date

___________________________________________________ _________________________________________________

Printed Name of Patient or Legal Representative Relationship to Patient – Proof of legal authority may be required

Release of

Information

Atrius Health

1177 Providence Hwy

Norwood, MA 02062

Tel: 781

292

7700 Fax: 617

421

2626