Instructions for Requesting Medical Records

To request your medical records, fill out the Authorization for the Disclosure of Protected Health Information form. 

Download the form in your preferred language: 

English  |  Spanish  |  Portuguese  |  Albanian  |  Vietnamese  |  Arabic 

 

You can also pick up the form at these locations:

  • University Campus, 55 Lake Avenue North, Worcester
  • HealthAlliance-Clinton Campus, 60 Hospital Road, Leominster

To avoid delays in the process of the release:

  • Fill out the form completely
  • Use clear handwriting

Once signed and completed, you can fax or email the authorization back to us. 

  • By fax: 508-334-9717
  • By email: M...