Fill in a Valid Massachusetts B Form
Article Structure
The Massachusetts B form serves a crucial role in the process of obtaining medical imaging records, specifically for dental purposes. This form, issued by Massachusetts General Hospital's 3D Imaging Service, allows patients to authorize the release of their CT dental images to designated recipients, such as new dentists. Key components of the form include the patient's name, date of birth, and medical record number, which ensure accurate identification and retrieval of the correct medical images. Additionally, the form requires the name and contact information of the new dentist, along with options for mailing the images either to the patient or directly to the dentist. Patients must also specify the date of the study and the type of media in which the images will be provided, such as a CD or DICOM CD. To facilitate the shipping process, patients are encouraged to call the lab with their shipping details. The form concludes with a signature line for the patient, underscoring the importance of consent in the sharing of medical information. Overall, the Massachusetts B form streamlines the transfer of essential dental imaging data while prioritizing patient privacy and consent.
Massachusetts B Example
FORM B
R) MASSACHUSETTS
•GENERAL HOSPITAL
IMAGING
3D Imaging Service
55 Fruit Street - Gray 267C
Boston, MA 02114
Telephone: (617)
Fax: (617)
Authorization for Release of CT Dental Images
Patient Name: ________________________________________________________
(print please)
Date of Birth: _________________________
Medical Record #: ______________________-
I hereby authorize Massachusetts General Hospital to furnish medical images from my image file.
NEW DENTISTS’S NAME: _______________________________________
DENTIST’S TELEPHONE#:_______________________________________
MAIL TO (CHECK ONE) D
PATIENT OR D
NEW DENTIST
MAILING ADDRESS:_______________________________________
_________________________________________
_________________________________________
Date of Study:__________
Simplant Version (Simplant Pro or Version 7 above)______________________________
Media Type: (CD or DICOM CD or Prints)______________________________________
Please call Lab at (617
__________ |
_______________________________________ |
Date |
Patient Signature |
Please fax this form back to the 3D Imaging Lab at
Revised 5/16/11
Form Specs
| Fact Name | Description |
|---|---|
| Purpose of the Form | The Massachusetts B form is used to authorize the release of CT dental images from Massachusetts General Hospital. Patients must complete this form to ensure their medical images are shared with their new dentist or themselves. |
| Patient Information Required | Patients must provide essential information, including their name, date of birth, and medical record number. This information helps to identify the patient and retrieve the correct medical images. |
| Mailing Options | The form offers two mailing options: patients can choose to have their images sent directly to themselves or to their new dentist. This flexibility ensures that patients can manage their dental care effectively. |
| Governing Law | This form is governed by Massachusetts state laws regarding patient privacy and the release of medical records, specifically under the Massachusetts General Laws Chapter 111, Section 70. |
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