General MIT Medical Forms and Documents

• Health history forms
  • Adult Patient Health History in English, Chinese (traditional), Chinese (simplified), Japanese, Russian, Spanish, and Korean
  • Adult Dental Patient Health History in English, Chinese, Japanese, Korean, and Spanish
  • Pediatric Health History in English, Chinese, Japanese, Korean, Russian, and 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 English, Chinese (traditional), Chinese (simplified), Japanese, Russian, Spanish, and Korean
  • Notice of Privacy Practices – MIT Health Plans (Traditional, Student Extended Insurance, Affiliate Extended Insurance)
  • Patient Rights and Responsibilities in English, Chinese (simplified), Chinese (traditional), Japanese, and 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