General MIT Medical Forms and Document
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
(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
- 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
Pediatric care forms
- Consent for treatment of a minor (a parental consent allowing another specific adult(s) to authorize medical care for a child in the parent's absence)
- Pediatric health history form in:
- Massachusetts certificate of immunization
- Massachusetts school health record form
- Massachusetts school immunization requirements
Wellness class registration
Class registration (Community Wellness at MIT Medical)
