Medical Records and Health Information Services
To request copies of your medical records, please follow the instructions below. Be sure to download and sign the release form.
Authorization to Release Information Form
Instructions for filling out the "Authorization to Release Information" form if you are the patient. If you have questions, please call Health Information Services at (207) 973-7873
If you are requesting records on someone other than yourself, please contact HeIS Correspondence at (207) 973-7877 to find out what may be needed.
1. In the patient identification box found in the upper left hand corner of the form, please write:
Your name (Please provide maiden or previous last names for which records would be located under, as well as your current last name)
Date of birth
2. On the lines provided for the name of the person(s) to whom records are to be released to, please write the name, address and phone number for each recipient. If the information is for you, the patient, just write "self".
3. Please list dates of services requested, if exact date is not known, please provide a date range.
4. Please be specific on the type of records you are requesting i.e. all cardiology, all x-rays, abstract of all records etc.
5. The State of Maine Statue requires a "Purpose" for all records requests; please select one from the list.
6. The authorization will expire in 12 months from the signature date. If you would like it to expire sooner, please enter a date.
7. There are three questions that we are required to ask all people requesting medical records according to mandates of the State of Maine. We need the patient's or authorized representative to give us permission to release records that pertain to the treatment or diagnosis of drug or alcohol abuse, mental health, HIV infection, ARC or AIDS.
On questions 1, 2 (part 1) and 3, if you check the boxes, that means you are giving Northern Light Eastern Maine Medical Center permission to process and send these records out.
If you know these records will not contain such information, or you do not want that information released you should leave them unanswered.
On question 2 (part 2), which pertains to mental health treatment or diagnosis, check if you wish to review the mental health information before it is released and if you do not please leave it unmarked.
9. You have a right to revoke this authorization. Since this is an authorization form for multiple Northern Light Health facilities, a written request would have to be submitted to the entity who acted upon it, so please write Northern Light Eastern Maine Medical Center on the line provided.
10. Lastly, sign on the patient line and date the form.
Health Information Services
Northern Light Eastern Maine Medical Center
43 Whiting Hill Rd., Suite 100
Brewer, Maine 04412