Authorization to Disclose


The Federal Privacy Law (HIPAA) enacted on 4/14/03 requires certain elements to be contained on all authorizations for disclosure of protected health information (your medical records). The attached Hallmark Health System Authorization Form includes all of the required elements.

Please Note: Hallmark Health System will not process requests for the release of medical information based on an invalid authorization form that does not include all of the required elements.

Please print [choose "fit to print"], sign and return your completed   Authorization to Use & Disclose Protected Health Information Form  to the Hallmark Health System organization for which your request is directed.

If you have any questions, please contact our Medical Records/HIM Dept at:

Lawrence Memorial Hospital (P) 781-306-6555 (F) 781-306-6551

Melrose-Wakefield Hospital (P) 781-979-3213 (F) 781-979-3217

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