Release of Health Information

Copies of medical records can be requested and obtained through Codman Square Health Center’s Health Information Management Service (HIMS) Department.

To get copies of your medical record, fill out a release of information consent form. Complete the request and return it to the HIMS Department.

All requests must be in writing. You may mail or fax a written request, which must contain the following elements to assist us in identifying your record(s). The written request must include:

  • A legible copy of a Government Photo ID, such as a valid driver’s license, state-issued ID, Passport or Military ID.
  • Patient’s full name (previous name[s], date of birth, address, and Social Security number)
  • Name of recipient, address, phone number (who is to receive information)
  • Type of information requested (exact information you want released)
  • Purpose of release (what information is being requested)
  • Approximate date of treatment
  • Appropriate signature with witnessed signature
  • Date of request
  • Expiration date of request (not to exceed one year from date of request)

All requests can take up to 30 days to complete, however the HIMS department will try to complete the request within 14 days.

When you sign up for MyChart, you’ll have access to select healthcare records, 24 hours a day, 7 days a week.

Contact Codman’s Health Information Department

Telephone Number

Fax Number

Hours of Operation
Monday – Friday, 8:30 am – 5 pm

You may mail written requests to:
Health Information Department
Codman Square Health Center
637 Washington Street
Dorchester, MA, 02124

Note: A fee is not assessed for copies of medical records for continuity of care (physicians or hospitals). However, copies of records for reasons other than continuity of care are subject to a copy fee. These include but are not limited to: legal requests, investigative agencies, insurance companies, etc. If you have any questions, please contact the Health Information Management Service Department.

Authorize the Release of Protected Health Information

Click below for the Release Form to Authorize the Release of Protected Health Information (PHI)

Medical professionals working on their computers