Form MADS-MR "Medical Records Release Form" - Massachusetts

What Is Form MADS-MR?

This is a legal form that was released by the Massachusetts MassHealth - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2015;
  • The latest edition provided by the Massachusetts MassHealth;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MADS-MR by clicking the link below or browse more documents and templates provided by the Massachusetts Masshealth.

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Download Form MADS-MR "Medical Records Release Form" - Massachusetts

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MassHealth
Medical Records Release Form
Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth
MassHealth Disability Evaluation Service
This MassHealth Medical Records Release Form helps us get medical information from your health-care provider so that the
MassHealth Disability Evaluation Service (DES) can make a disability determination.
Please read the instructions carefully before you fill out this form. If you leave any sections of this form blank, this permission will
not be valid, and the health-care provider will not be able to share your information with the MassHealth DES. If the health-care
provider does not share medical information with the MassHealth DES, we will not be able to make a disability determination.
General instructions for filling out the Medical Records Release Form
You must follow these instructions when filling out the Medical Records Release Forms. The health-care providers will not send
medical records to the MassHealth DES if you do not fill out the forms the right way. We need copies of medical records to make a
disability determination.
1.
Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other
health-care provider you listed in the Disability Supplement.
2. All signatures must be in ink and must be originals. No copies or stamps of signatures are permitted.
3. Only one signature may appear on a line.
4. If this form is for a child younger than age 18, one parent or legal guardian must sign for the child.
SECTION I
Permission is given for the health-care provider listed in Section II to share the medical information listed in Section III about
with the MassHealth DES.
(Please print name of applicant or member.)
SECTION II
Please print the name of the health-care provider that may share medical information with the MassHealth DES.
Name of doctor, health center, or other health-care provider
Street address
City, state, zip
Phone (
)
SECTION III
The health-care provider listed in Section II above may share the following information with the MassHealth DES to determine
eligibility for MassHealth benefits.
All medical records or other information about my treatment, hospitalization, or outpatient care for conditions including
psychological/psychiatric impairments
how impairments affect activities of daily living and ability to work
AIDS/HIV
drug and alcohol use
other (please describe)
Check here if you do not want the health-care provider to share information about AIDS/HIV status.
Check here if you do not want the health-care provider to share information about drug or alcohol use.
MADS-MR (Rev. 04/15)
(continued on back)
MassHealth
Medical Records Release Form
Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth
MassHealth Disability Evaluation Service
This MassHealth Medical Records Release Form helps us get medical information from your health-care provider so that the
MassHealth Disability Evaluation Service (DES) can make a disability determination.
Please read the instructions carefully before you fill out this form. If you leave any sections of this form blank, this permission will
not be valid, and the health-care provider will not be able to share your information with the MassHealth DES. If the health-care
provider does not share medical information with the MassHealth DES, we will not be able to make a disability determination.
General instructions for filling out the Medical Records Release Form
You must follow these instructions when filling out the Medical Records Release Forms. The health-care providers will not send
medical records to the MassHealth DES if you do not fill out the forms the right way. We need copies of medical records to make a
disability determination.
1.
Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other
health-care provider you listed in the Disability Supplement.
2. All signatures must be in ink and must be originals. No copies or stamps of signatures are permitted.
3. Only one signature may appear on a line.
4. If this form is for a child younger than age 18, one parent or legal guardian must sign for the child.
SECTION I
Permission is given for the health-care provider listed in Section II to share the medical information listed in Section III about
with the MassHealth DES.
(Please print name of applicant or member.)
SECTION II
Please print the name of the health-care provider that may share medical information with the MassHealth DES.
Name of doctor, health center, or other health-care provider
Street address
City, state, zip
Phone (
)
SECTION III
The health-care provider listed in Section II above may share the following information with the MassHealth DES to determine
eligibility for MassHealth benefits.
All medical records or other information about my treatment, hospitalization, or outpatient care for conditions including
psychological/psychiatric impairments
how impairments affect activities of daily living and ability to work
AIDS/HIV
drug and alcohol use
other (please describe)
Check here if you do not want the health-care provider to share information about AIDS/HIV status.
Check here if you do not want the health-care provider to share information about drug or alcohol use.
MADS-MR (Rev. 04/15)
(continued on back)
SECTION IV
Any medical information that the health-care provider releases to the MassHealth Disability Evaluation Service (DES) will
continue to be protected by federal privacy laws.
This permission to release medical information to the MassHealth DES ends six months from the date you sign this release
form, unless you have cancelled permission in writing before then.
I understand that I may cancel this permission at any time by sending a letter to the health-care provider I listed in Section II.
I understand that even if I cancel this permission, the health-care provider I listed in Section II cannot take back any information
that it shared with the MassHealth DES when it had my permission to do so.
I also understand that my decision whether to give the health-care provider permission to share medical information with the
MassHealth DES is voluntary. However, I also understand that if I do not give permission to the health-care provider to share
medical information with the MassHealth DES, the MassHealth DES will not be able to make a disability determination, and the
decision about eligibility for MassHealth benefits will be made without consideration of any disability claimed.
SECTION V
Signature of applicant/member
Date
Print name of applicant/member
Phone (
)
Street address
Date of birth
City/Town
State
Zip code
If this form is being filled out by someone who has the legal authority to act on behalf of the applicant/member
(such as the parent of a minor child, an eligibility representative, or a legal guardian), please give us the following information.
Signature of person filling out this form
Print name
Date
Authority of person filling out this form to act on behalf of the applicant/member
Please give us a copy of the document that gives this person the authority to act on behalf of the applicant/member.
MassHealth will send you back a copy of this signed Medical Records Release Form for you to keep for your
records. You can also ask for another copy of this signed Medical Records Release Form at any time by
contacting MassHealth at the following address.
Disability Evaluation Services
UMASS Medical DES
P.O. Box 2796
Worcester, MA 01613-2796
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