MEDICAL RECORD RELEASE FORM

To:

• release copies of your medical record,
• review your medical record,
• or obtain copies of your medical record from another facility

please print, complete, and mail the medical record release form to:

Bulfinch Medical Group
Wang Ambulatory Care Center
15 Parkman Street- 5th Floor
Boston, MA 02114

OR

Fax the completed form to (617) 724-6649

PLEASE NOTE: There is a 3 week turnaround time to process your request.

If you have any questions regarding the release please contact Angela Perri at (617) 724-6678.

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