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@research.bwh.harvard.edu. It is an important part of the study that we obtain medical records relating to your diagnosis and/or hospitalization to confirm that the event has occurred during the course of follow-up. Therefore, in the event that you have received a new medical diagnosis and/or undergone hospitalization, we will send you a medical record release form for permission of release. The records that we obtain will solely pertain to the single event that you reported and will be kept confidential

At this time, we are pursuing reports of cardiac arrest and implantable cardiac defibrillator device (ICD) implantation, as well as ICD follow-up (i.e. device interrogations/remote monitoring). If you have reported one or both, 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 release forms. If you have lost or misplaced the release form, please either call our main study line and we will re-mail 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

• ICD Medical Record Release Form
• Cardiac Arrest Medical Record Release Form
• Combined ICD/Cardiac Arrest Medical Record Release Form (use this form if you have had both events)

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. Please take a moment to inform your family/contacts that we will reach out to them in such event.