EOPSS-OCME

REQUEST FOR MEDICAL EXAMINER’S REPORT- INSURANCE COMPANIES

Pursuant to G.L. c. 38, § 2, and 505 CMR 1, the office of the Chief Medical Examiner (OCME) may, in its discretion, provide a copy of an autopsy report (if available) upon request to those who are legally entitled to receive them.

In cases of unnatural or suspicious death where the district attorney or his law enforcement representative is directing and controlling the investigation of the death pursuant to G.L. c. 38, § 4, the OCME may only provide a copy of the autopsy report after the district attorney or his law enforcement representative has determined, in his discretion and in writing, that he does not object to the disclosure of the autopsy report.

To request a copy of an autopsy and/or toxicology report or a Medical Examiner Statement (Insurance Purposes), complete this form and submit it to our office via email at CMEAdmins1@mass.gov or by standard US Postal Service to the following address:

Office of the Chief Medical Examiner
Attn: OCME Report Request
720 Albany Street
Boston, MA 02118

Legal Next of Kin Authorization

Legal Next of Kin Printed Name(Required)

Relationship(Required)

Wet signature required: Do not sign electronically. After completing the online form, print the generated document and sign the line below in ink.

Legal Next of Kin Signature

Required Information

1. Decedent Information

Full Name of Decedent(Required)

Date of Birth(Required)

Date of Death(Required)

OCME Case Number (if known)

Leave this field blank if the case number is not known.

2. Requested Documents(Required)

Select all documents being requested.

Autopsy Report

Toxicology Report

No Foul Play Letter (For Insurance Company only)

3. Legal Next of Kin Authorization – This request requires the signature of the legal next of kin (see above). Requests submitted without proper authorization will be denied.

4. Insurance Company Information

Insurance Company Name(Required)

Claim/Policy Number(Required)

Enter the claim or policy number exactly as assigned.

Contact Person Name(Required)

Mailing Address(Required)

Enter the mailing address where the authorized recipient can receive the requested reports.

Street Address Suite, Unit, or Floor (optional) City State ZIP Code

Phone Number(Required)

Include the area code.

Fax Number

Leave blank if the insurance company does not use fax.

Email Address(Required)

Enter the insurance contact’s email address.

Enter Email Confirm Email

Wet signature required: Do not sign electronically. After completing the online form, print the generated document and have the insurance agent sign the line below in ink.

Insurance Agent Signature