Record Request Form

Client's Name

Client's DOB

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I am requesting the following from my medical record (select all that apply):

Other

What date(s) are you requesting records from?

I would like to receive my medical record by:

For your security, please provide a picture of your ID (or the guardian's ID)

Date

Signature of patient (or parent / guardian)

Your record will be available within 5-7 business days after you have submitted this request.

IBC follows record retention guidelines set forth by the Commonwealth of Massachusetts. Records for adult patients are maintained for 7 years. Pediatric records are maintained for 7 years or until the individual turns 18.

Requested psychotherapy records are provided after clinical review. If the content of the record could adversely affect the patient's wellbeing, a summary of the record will instead be provided in accordance with Commonwealth of Massachusetts G.L. c. 112, § 12CC and 243 CMR 2.07 (13)(e).

Are you a former client of General Psychological Associates and requesting records prior to June 10, 2024?

You will additionally need to submit a record request form through GPA. You will be redirected to the form on the next page. All information will be required again as this is a separate entity.