Request your medical history from your treatment and time with Walden

Authorization Forms

Authorization to Release/Disclose PHI
Amendment of PHI

1. Complete the authorization form. Please complete the following required fields properly to process the request:

• Patient’s full name (include maiden name, if applicable)
• Address and telephone number
• Email address
• Date of birth
• Medical record number, if available
• Date of service
• Provider name or facility or clinic name requesting records from

Identify the method for us to share the requested medical records by clearly indicating the mailing address, fax number, email address

2. Sign and date the completed authorization form.
3. Fax or mail your request with all required information included.

Release of Information Fax: 781-647-0215
Mailing Address:
Walden Behavioral Care
Medical Records
10 Carematrix Drive
Dedham, MA 02026

Important Reminders

Do not e-mail this request. We cannot guarantee security of all Personally Identifiable Information included in the form if submitted via e-mail.
Additional authorization may also be required for the release of specifically protected or privileged information. Certain information can take up to 30 days to process.
For Release of Information questions, please call Customer Service at 781-647-6782.
For Audit-related questions, please call 781-647-6704 or fax 781-647-0215.

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