MEDICAL RECORDS
At Merrimack Family Medicine, we respect your privacy. If you would like a copy of your medical record or require us to forward a copy to a new healthcare provider, we need your written authorization along with a legible copy of your valid photo ID (18 years or older).
Please provide a date range of service, that identifies the information you need – for example, “all records from 2000-present date”.
There are three options to obtain copies of your medical records:
- Stop by the office at 600 Clark Road to fill out a Consent to Release form and present your valid photo ID.
- Download and complete the Consent to Release Medical Records Form and mail it to us at the address below.
- Download and complete the Consent to Release Medical Records form and fax it to 978-788-7911.
Is there a charge for medical records?
There is NO charge if we send the records directly to a specialist in conjunction with your PCP’s approved referral, or if you have decided to change Primary Care Providers and they fax a signed release form.
There is a charge for copies of medical records that you pick up. Guidelines legislated by the State of MA, is $0.72 per page up to 100 pages and $0.37 per page thereafter.
Third party requestors, such as insurance companies and attorneys, are also subject to these fees.
Please print the Consent to Release Medical Records form, complete it and mail to:
Medical Records
Merrimack Family Medicine
600 Clark Road, Suite 3
Tewksbury, MA 01876
Requests can take 7-10 business days for processing.
Downloadable Documents