Medical Record Release forms

If you have had a recent cardiac-related medical diagnosis and/or hospitalization, please be sure to inform us of this event on your next follow-up questionnaire or contact us in advance at (877) 718-8003 or predetermine@partners.org. It is an important part of the study to obtain the medical records relating to your diagnosis and/or hospitalization to confirm that the event has occured during the course of follow-up. Therefore, in the event that you have received a new medical diagnosis and/or undergone a hospitalization, we will send you a medical record release form for permission of release. The records that we obtain will solely pertain to the event that you reported and will be kept confidential.

At this time, we are pursuing reports of implantable cardiac defibrillator (ICD) device implantation and cardiac arrest. If you have reported one or both of these events, you may receive a medical record release form for permission of release via mail if you have not already. Below you can view the medical record release forms. If you have lost or misplaced the release form, please either call our main study line and we will send you a new form, or print one of the forms listed below and mail to: 

PRE-DETERMINE Study
Clinical Coordinating Center
Brigham and Women's Hospital
900 Commonwealth Avenue, Floor 3
Boston, MA 02215

 

In the event of death, we will need to contact your next-of-kin to confirm the cause of death by obtaining a copy of the death certificate and medical records. In addition, we may also need to gather information regarding the circumstances surrounding the event from your family members and/or friends.