Medical Records Request

Patient privacy has always been a priority at The Marino Center for Integrative Health. The privacy notice, various elements of which are mandated by federal law is lengthy and may be somewhat confusing. However, federal law has changed little in the practice of the release of Protected Health Information (PHI), and the laws of Massachusetts governing PHI are actually stricter than federal law. Therefore, the release of PHI requires more paperwork, available below. An authorization to release PHI must be signed by the patient, or the patient's legal representative (guardian or person with durable power of attorney).

A request for medical records form is available below to print. Please complete the form and submit to:

Medical Records Department
The Marino Center for Integrative Health
372 Washington Street
Wellesley, MA 02481

Please download and complete the Authorization to Release Protected Health Information Form for Medical Records release.  Please print legibly and remember to sign both pages if there are more than one. We cannot accept requests sent over the Internet at this time.

There is a charge to cover the cost of producing copies. There is a single processing fee of $10 per request, with an additional $0.50 per page for the first 100 pages, and $0.25 per page thereafter.

There is no charge for you to request The Marino Center for Integrative Health to send reports directly to another hospital, nursing home or physician; we are aware of the need to expedite information for patient care. These requests are our highest priority. 

If you have comments or questions regarding your medical records, please contact the Medical Records Department at 781-235-5200 ext. 7978.