Healthcare Proxy & Medical Record Release Forms

This is a resource with forms and links you may need as a patient of MelroseWakefield Healthcare.

Please note: MelroseWakefield Healthcare was formerly known as Hallmark Health. We are in the process of updating these documents.

Healthcare Proxy

A healthcare proxy should be established so that your “healthcare agent” can make medical decisions for you if you become incapable of making your own medical decisions (e.g. due to unconsciousness, dementia or other mental limitations).

Healthcare Proxy (English)

Healthcare Proxy (Spanish)

Healthcare Proxy (Vietnamese)

Medical Record Release Form

The Federal Privacy Law (HIPAA) enacted on 4/14/03 requires certain elements to be contained on all authorizations for disclosure of protected health information (your medical records).

AUTHORIZATION TO USE & DISCLOSE PROTECTED HEALTH INFORMATION FORM

If you have any questions, please contact our medical records department at Lawrence Memorial Hospital at 781-306-6555 or MelroseWakefield Hospital at 781-979-3213.

Medication Form

Medication errors can be prevented if your medication records are accurate, up-to-date and accessible to your physician. Since it’s not always easy to remember what medications you are taking, we are providing you with a framework for listing your medications before you come for your visit or surgery.

CURRENT MEDICATION LIST

Birth Certificate Request

You can order a replacement birth certificate from the Commonwealth of Massachusetts Registry of Vital Records and Statistics.

ORDER A BIRTH CERTIFICATE