Request for Beth Israel Deaconess - Plymouth medical records/Authorization to use & disclose PHI
Diagnostic Imaging Release Form
Patients have the right to obtain a copy of their medical records from Beth Israel Deaconess - Plymouth. You must submit your request in writing. You may accomplish this in several ways:
- Use the request form provided by Beth Israel Deaconess - Plymouth (preferred method). Download and print out a request form by clicking here. Return the form to Beth Israel Deaconess - Plymouth at the address listed below.
- Submit a letter of request. In order for us to help you, the letter must include the following information:
a. Dates of your service at Beth Israel Deaconess - Plymouth.
b. The purpose of your request: legal, medical follow-up, insurance or personal.
c. The name/address of the person who is to receive the records.
d. Your signature and date the letter was written.
Submit the written request to Beth Israel Deaconess - Plymouth at the following address:
Beth Israel Deaconess - Plymouth
Medical Records Department
275 Sandwich Street
Plymouth, MA 02360
Fax the form or letter to 508-830-2560.
There may be a fee associated with processing your request depending on the number of pages photocopied. Call the release of information help desk at 508-830-2363 for more information.
You can only request your own medical record, unless you are requesting a copy of a minor child/children (under 18 years of age). In the event that a patient is deceased, the executor of the estate can request copies of records. The executor must mail in a copy of the executor paperwork in addition to the written request. If no executor is appointed, the next of kin may request photocopies.
Each subsequent request of medical records requires an additional written request, form or authorization.
For general information about medical records, call 508-830-2361.