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Medical Records Requests (English and Español)

Your medical record itself belongs to the hospital, but as a patient, you have the right to review and/or obtain a copy of your own medical information. Patient-related information may also be released to a physician or medical facility for care of the patient when needed. Our process for requesting medical records varies slightly by location. Please see details below.

Your Medical Record Requests

Medical Record Requests: Burbank and Leominster Campuses

To review or receive a copy of your medical record or to have your medical record forwarded to another party please fill out the form below:

Authorization for the Disclosure of Protected Health Information (English)

Authorization for the Disclosure of Protected Health Information (Spanish)

Authorization for the Disclosure of Protected Health Information (Portuguese)

Authorization for the Disclosure of Protected Health Information (Albanian)

Authorization for the Disclosure of Protected Health Information (Vietnamese)

Authorization for the Disclosure of Protected Health Information (Arabic)

Please note: A fee for photocopies may apply per Massachusetts General Law, Chapter 111, Section 70.

If you would like an electronic copy of your medical records, complete the Electronic Record Delivery Letter in English form.

Mail or fax completed authorization form to:

UMass Memorial HealthAlliance-Clinton Hospital c/o Correspondence 
60 Hospital Road 
Leominster, MA 01453 
Fax: 978-466-2789

Processing of Medical Record Requests: Burbank and Leominster Campuses

Upon receipt of the signed release form, we will begin to process the request. Please allow at least 15 to 20 business days for the processing of a request.

Once we have processed your request, HealthPort (HealthAlliance-Clinton Hospital’s release of information partner) will print, package, mail and invoice you for the records.  

  • Inquiries regarding request status: Please contact HealthAlliance-Clinton Hospital at 978-466-2857 or 978-466-2834 to inquire about the status of your request. 
  • Invoicing information: The invoice will be sent from HealthPort directly to you with the requested records and is payable to: HealthPort Technologies. Please contact HealthPort Technologies at 800-367-1500, if you have any invoice questions.
  • Questions: For further information regarding the release of medical records, please call the Health Information Services Department, weekdays from 8 am to 4 pm at 978-466-2857 or 978-466-2834.

Medical Record Requests: Clinton Campus

To request a copy of your medical records, please complete one of the forms above. Please note that a fee for copying will be charged.

Return the completed form to:

Health Information Management
HealthAlliance-Clinton Hospital
201 Highland Street
Clinton, MA 01510

Questions: Contact 978-368-3801 or 978-368-3839, or email.

Processing of Medical Record Requests: Clinton Campus

  • To other health providers: Medical records can be sent to another facility with the patient's written consent. Such requests may take up to two weeks to complete. 
  • Faxing medical information: To decrease the likelihood of a fax being sent to an unintended recipient or an individual, we do not fax medical information except in medical emergencies. 
  • Forms for school, insurance or work: Patients who need a form completed for these purposes should complete their portion of the form and sign an authorization for the release of information. Please let us know when the form will be picked up or if it should be mailed. Please allow one week for the forms to be processed. 
  • Workers' compensation: Massachusetts General Laws require that a medical report pertaining to any injury that appears to be compensable under worker's compensation be furnished to the employee, employer and insurer within 14 days of completion of examination. Please note: if a patient denies release of information, it may be necessary to adjust his/her account to a self-pay status.