beth israel deaconess medical center a harvard medical school teaching hospital

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Beth Israel Deaconess HealthCare

Notice of Privacy Practices (HIPAA)

This notice describes how medical information about patients may be used and disclosed and how patients can get this information.

Medical Records Release Authorization Form

This form will allow patients to authorize copies of their medical information to be released to person/ facility named. Completed forms should be sent by mail or fax to your physician’s office for processing.  Processing time varies depending on the type of request and method of delivery.  If you wish to pick up the records in person, please include that information on the form.

Health Care Proxy Form

This form will allow you to designate an individual to make health care decisions on your behalf in the event you become unable to make or communicate such decisions yourself.

Authorization to Make Medical Decisions for a Minor

This form should be completed by a parent or guardian of a patient who is under the age of 18 to name a person who will be present at the patient’s medical appointment. By completing this form you are authorizing that person to consent to care for the patient on your behalf. This form expires after 60 days. If the parent or guardian wishes to remove this designation, please call the patient’s physician’s office.

Caregiver Authorization Form

This form should be completed by a parent or guardian of a patient who is under the age of 18 to name a person who lives with the patient and will be assisting with the care of the patient by bringing them to medical appointments. By completing this form you are authorizing that person to consent to care for the patient on your behalf.  This form expires after two years.  If the parent or guardian wishes to remove this designation, please call the patient’s physician’s office.

Request for Amendment of Health Information

This form should be completed when a patient requests a change, edit or update of medical record information.  For changes in ongoing care such as your medication list or medical conditions, please contact your provider.

Notice of Non-Discrimination

Beth Israel Deaconess HealthCare (BIDHC) complies with applicable federal and state civil rights laws and does not discriminate on the basis of your race, color, national origin, citizenship, alienage, religion, creed, sex, sexual orientation, gender identity, age, disability, or any other status protected by applicable laws.