Upham’s Corner Health Committee, Inc.
Upham’s Corner Health Center ~ Upham’s Corner H.C. Pharmacy ~ Upham’s Elder Service Plan ~ Upham’s Home Health
e415 Columbia Road
Dorchester, MA 02125(617) 287 - 8000
AUTHORIZATION FOR RELEASE OF PROTECTED OR PRIVILEGED HEALTH INFORMATION I, or the parent/guardian of the patient named below, understand that I have the right to inspect my protectedhealth information at UCHC, to receive a copy of my protected health information (or designate and authorizesomeone else to receive a copy of it), or any combination of such. I understand that my request to access myrecords may be subject to some legal limitations and/or limitations established by the federal government and enforced by a licensed healthcare professional to assure my health and safety and the safety of others