General MIT Medical Forms and Documents

• Health history forms
  • Adult Patient Health History in Adult Patient Health History form in English, Adult Patient Health History form in Chinese (traditional), Adult Patient Health History form in Chinese(simplified), Adult Patient Health History form in Japanese, Adult Patient Health History form in Russian, Adult Patient Health History form in Spanish, and Adult Patient Health History form in Korean
  • Adult Dental Patient Health History in Adult Dental Patient Health History form in English, Adult Dental Patient Health History form in Chinese, Adult Dental Patient Health History form in Japanese, Adult Dental Patient Health History form in Korean, and Adult Dental Patient Health History form in Spanish
  • Pediatric Health History in Pediatric Health History form in English, Pediatric Health History form in Chinese, Pediatric Health History form in Japanese, Pediatric Health History form in Korean, Pediatric Health History form in Russian, and Pediatric Health History form in Spanish
• Medical record forms
  • Authorization for Release of Protected Health Information
    (Medical Record) by MIT Medical
  • Authorization for Release of Protected Health Information
    (Dental Record) by MIT Medical
  • Authorization for Release of Protected Health Information
    (Mental Health Record) by MIT Medical
  • Authorization for Release of Protected Health Information
    (Medical Record) to MIT Medical
  • Authorization for Release of Protected Health Information
    (Mental Health Record) to MIT Medical
  • Request for Amendment of Protected Health Information
• Patient privacy / advocacy / rights
  • Notice of Privacy Practices – MIT Medical Department in Notice of MIT Medical Privacy Practice in English, Notice of MIT Medical Privacy Practice in Chinese(traditional), Notice of MIT Medical Privacy Practice in Chinese (simplified), Notice of MIT Medical Privacy Practice in Japanese, Notice of MIT Medical Privacy Practice in Russian, Notice of MIT Medical Privacy Practice in Spanish, and Notice of MIT Medical Privacy Practice in Korean
  • Notice of Privacy Practices – MIT Health Plans (Traditional, Student Extended Insurance, Affiliate Extended Insurance)
  • Patient Rights and Responsibilities in Patient Rights and Responsibilities in English, Patient Rights and Responsibilities in Chinese (simplified), Patient Rights and Responsibilities in Chinese (traditional), Patient Rights and Responsibilities in Japanese, and Patient Rights and Responsibilities in Korean
• MIT Pharmacy forms
  • Home Delivery from MIT Pharmacy (request form)
  • Release for Pharmacy Patient Prescription Profile
• Wellness class registration
  • Class registration (Community Wellness at MIT Medical)
• General medical and healthcare forms
  • Massachusetts
    • Healthcare Proxy