Massachusetts State Seal An official website of the Commonwealth of Massachusetts Here's how you know

Official websites use .mass.gov

A .mass.gov website belongs to an official government organization in Massachusetts.

Secure websites use HTTPS

A lock icon or https:// means you've safely connected to the official website. Share sensitive information only on official, secure websites.

Skip to main content

DMH Privacy Forms

These forms may be used by individuals who wish to communicate with the Department of Mental Health to authorize the release of, or amend, restrict, or request access to their protected health information. The forms may be downloaded and printed as needed.

Skip table of contents
You skipped the table of contents section.

One Way Release of Information Forms

Authorization Form-One Way From DMH, Open PDF file, 231.04 KB (English, PDF 231.04 KB)
Authorization Form-One Way To DMH, Open PDF file, 230.05 KB (English, PDF 230.05 KB)

Two Way Release of Information General Use Forms

Authorization Form General Use - Two Way , Open PDF file, 257.93 KB (English, PDF 257.93 KB)

Two Way Release of Psychotherapy Notes Forms

Authorization Form Psychotherapy Notes - Two Way, Open PDF file, 201.19 KB (English, PDF 201.19 KB)

Additional Authorization Forms

Authorization For Photo, Audio, Video (PDF)
Authorization for Photo, Video, Audio (Spanish)
Release of Information for Social Supports

Additional Privacy Forms

Revocation of Authorization (PDF)
Request to Inspect PHI (PDF)
Request to Amend PHI (PDF)
Audit Trail Request Form (PDF)
Confidential Communications Request (PDF)
Restriction Request Form (PDF)
Privacy Complaint (PDF)
Attestation Regarding a Requested Use or Disclosure of Protected Health Information Potentially Related to Reproductive Health Care (PDF)

Recovery From Addictions Program (RAP) Forms

RAP Authorization for Release of Information Two-Way
RAP Authorization for Release of Substance Use Disorder Counseling Notes
RAP Authorization for Release of Records for Legal Proceedings
RAP Substance Use Disorder Re-Disclosure Notice

Help Us Improve Mass.gov  with your feedback

Please do not include personal or contact information.
Feedback