eohhs-dmh

Requestor Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Name of Academic Research Institution(Required)

Website of Academic Research Institution(Required)

Description of Research(Required)

Deceased Patient & Facility Information

Researcher Has Information Showing Date of Death of Specific Former Patients

Researcher Doesn’t Have Information Showing Date of Death

Researcher Has Information Showing Date of Death of Specific Former Patients.(Required)

Drop files here or

Max. file size: 20 MB, Max. files: 1.

Attach list showing (1) Name of deceased patient, (2) DMH facility, and (3) general timeframe when the patient was admitted to the DMH facility, along with documents showing the date of death (e.g., individual’s death certificate or obituary).

DMH can only provide responsive patient medical records if DMH has documents showing that the former DMH client is deceased more than 50 years (i.e., DMH medical record documents date patient died or DMH received a death certificate after patient discharge.

Requestor Certification(Required)

I certify that the information above is complete and accurate under the pains and penalties of perjury (type first & last name).

Date(Required)