Behavioral Healthcare Services Forms
Release of Information Form (ROI)
The release of information form is necessary for us to be able to communicate with other care providers, organizations, employers, and other individuals for whom you would like us to share information with. This includes parents of patients who are over the age of 18. The patient or their legal guardian must sign any release of information forms for them to be valid.
Medical Records Request Form
The medical records request form is used to request medical records of a patient. These records can be requested by the patient for personal use, or by organizations for use in providing care or to assist in legal matters. In order for any person or organization other than the patient to request medical records, we must have a release of information on file, or the patient must sign off on the request. There is a charge per page for all records requested for personal use.
All completed forms must be faxed to Behavioral Healthcare Services at 508-752-7245. Forms may also be mailed to the office at 435 Shrewsbury Street, Worcester MA 01604. Behavioral Healthcare Services can not comply with any requests without a valid release of information or medical records request form.
Use the form below to submit a patient intake form. Intake forms are automatically emailed to the intake specialist and added to a wait list. Fields marked with an asterisk are required. Incomplete forms may not be processed. Submission of a form does not guarantee an appointment.