Record Request Form

Record Request Form

Integrated Behavioral Care, LLC
Client's Name*
Client's DOB*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I am requesting the following from my medical record (select all that apply):*

Neuropsychological testing reportDiagnostic assessmentTherapy progress notes, diagnoses, treatment goals, discharge summaryMedication management recordsFull mental health recordOther
What date(s) are you requesting records from?*
I would like to receive my medical record by:

Secure EmailPickup in Office (3 Dundee Park Drive Suite 203 Andover, MA 01810 on Mon,Tues,Thurs, or Fri)
For your security, please provide a picture of your ID (or the guardian's ID)*
Date*

MonthDayYear
Signature of patient (or parent / guardian)*

Clear
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?

YesNo
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.
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