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.