To receive a copy of your medical records:
Please complete and sign an Authorization to Release Protected Health Information form. Please allow five to ten days to process your request.
Authorization form - ENGLISH
Authorization form - HAITIAN CREOLE
Authorization form - PORTUGUESE
Authorization form - SPANISH
The completed hospital authorization form can be faxed to 508-427-2209 or 508-427-2291. You may also mail it to:
Health Information Services Department
Attention: Correspondence Unit at Good Samaritan Medical Center
235 N. Pearl St.
Brockton, MA 02301
Please address to Radiology Department ONLY if you require a copy of an image on CD.
For questions, please call the correspondence unit at 508-427-3180 during the following times:
- Monday - Friday: 8 a.m. - 5 p.m.