Authorization to Release Protected Health Information (Medical Records) Form
Download the request for images form
Although your medical record data and x-ray film belong to the hospital, the information contained in the record belongs to you. You may inspect the record or have copies made for a reasonable fee after signing an authorization. If you are a hospitalized patient, please make your request through a staff member. If you would like a copy of your record after discharge, please call the Lowell General Hospital Health Information Management Department at (978) 937-6000, ext. 76327.
Lowell General Hospital has a Patient Portal that does have some components of your medical information available for you to review. If you have not enrolled in the patient portal but would like to, please call one of the Patient Service Representative at 978-937-6400 for assistance.
At Lowell General Hospital, we respect your privacy. If you would like us to forward a copy of your medical record to a healthcare provider, we need your written authorization along with a legible copy of your valid photo ID. If you pick up your medical records in person, you will be required to show a valid photo ID.
When completing the authorization, please provide the date of service and the information you need, for example, “discharge summary from last admission.”
There are three options to obtain copies of your medical records:
- Stop by the Health Information Management Department and fill out an authorization to release your records and present a valid photo ID.
- Download and complete the Authorization to Release Protected Health Information (Medical Records) Form, and then mail it to us to the addresses below.
- Download and complete the Authorization to Release Protected Health Information (Medical Records) Form, and then fax it to 978-937-6869.
Is there a charge for medical records?
There is NO charge if we send the records directly to another healthcare provider.
There is a charge for copies of medical records that you pick up or those which are mailed directly to you. This fee is legislated by the state of Massachusetts. Payment for copies can only be made in cash or by check. Consideration will be given to waive fees for patients in cases of financial hardship.
Third party requestors, such as insurance companies and attorneys, are charged for copies which will be processed by Sharecare Health Data Solutions.
Please print the Authorization to Release Protected Health Information (Medical Records) Form complete it and mail to:
Health Information Management Department
Lowell General Hospital
295 Varnum Avenue
Lowell, MA 01854-2193