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.
- This page, DMH Privacy Forms, is offered by
- Massachusetts Department of Mental Health
DMH Privacy Forms
Table of Contents
One Way Release of Information Forms
Open PDF file, 10.41 KB,
Authorization Form-One Way From DMH
(English, PDF 10.41 KB)
Open PDF file, 10.32 KB,
Authorization Form-One Way To DMH
(English, PDF 10.32 KB)
Two Way Release of Information General Use Forms
Open PDF file, 137.32 KB,
Authorization Form General Use - Two Way
(English, PDF 137.32 KB)
Open PDF file, 2.99 MB,
(Fillable PDF) Authorization for Release of Information - Two Way
(English, PDF 2.99 MB)
Open PDF file, 278.93 KB,
Authorization Form General Use -Two Way (Spanish)
(English, PDF 278.93 KB)
Open PDF file, 282.21 KB,
Authorization Form General Use -Two Way (Portuguese)
(English, PDF 282.21 KB)
Open PDF file, 458.23 KB,
Authorization Form General Use -Two Way (Chinese Simplified)
(English, PDF 458.23 KB)
Open PDF file, 427.58 KB,
Authorization Form General Use -Two Way (Chinese Traditional)
(English, PDF 427.58 KB)
Open PDF file, 494.41 KB,
Authorization Form General Use -Two Way (Vietnamese)
(English, PDF 494.41 KB)
Open PDF file, 92.63 KB,
Authorization Form General Use -Two Way (French)
(English, PDF 92.63 KB)
Open PDF file, 1.07 MB,
Authorization Form General Use -Two Way (Arabic)
(English, PDF 1.07 MB)
Open PDF file, 340.71 KB,
Authorization Form General Use -Two Way (Cape Verdean Creole)
(English, PDF 340.71 KB)
Open PDF file, 361.62 KB,
Authorization Form General Use -Two Way (Khmer)
(English, PDF 361.62 KB)
Open PDF file, 485.23 KB,
Authorization Form General Use -Two Way (Russian)
(English, PDF 485.23 KB)
Open PDF file, 292.25 KB,
Authorization Form General Use -Two Way (Haitian Creole)
(English, PDF 292.25 KB)
Two Way Release of Psychotherapy Notes Forms
Open PDF file, 246.38 KB,
Authorization Form Psychotherapy Notes - Two Way
(English, PDF 246.38 KB)
Open PDF file, 182.93 KB,
(Fillable PDF) Authorization Form Psychotherapy Notes - Two Way
(English, PDF 182.93 KB)
Open PDF file, 273.66 KB,
Authorization Form Psychotherapy Notes - Two Way (Spanish)
(English, PDF 273.66 KB)
Open PDF file, 273.77 KB,
Authorization Form Psychotherapy Notes - Two Way (Portuguese)
(English, PDF 273.77 KB)
Open PDF file, 333.48 KB,
Authorization Form Psychotherapy Notes - Two Way (Cape Verdean Creole)
(English, PDF 333.48 KB)
Open PDF file, 391.72 KB,
Authorization Form Psychotherapy Notes - Two Way (Chinese Simplified)
(English, PDF 391.72 KB)
Open PDF file, 393.05 KB,
Authorization Form Psychotherapy Notes - Two Way (Chinese Traditional)
(English, PDF 393.05 KB)
Open PDF file, 400.82 KB,
Authorization Form Psychotherapy Notes - Two Way (Vietnamese)
(English, PDF 400.82 KB)
Open PDF file, 2.23 MB,
Authorization Form Psychotherapy Notes - Two Way (Arabic)
(English, PDF 2.23 MB)
Open PDF file, 83.53 KB,
Authorization Form Psychotherapy Notes - Two Way (French)
(English, PDF 83.53 KB)
Open PDF file, 324.95 KB,
Authorization Form Psychotherapy Notes - Two Way (Khmer)
(English, PDF 324.95 KB)
Open PDF file, 396.06 KB,
Authorization Form Psychotherapy Notes - Two Way (Russian)
(English, PDF 396.06 KB)
Open PDF file, 295.4 KB,
Authorization Form Psychotherapy Notes - Two Way (Haitian Creole)
(English, PDF 295.4 KB)
Additional Authorization Forms
Additional Privacy Forms
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