ORDER FOR INSPECTION AND FOR COPIES OF CERTAIN 
HOSPITAL RECORDS 
(Request Pursuant to Superior Court Rule 13)

Trial Court of Massachusetts 
The Superior Court 

DOCKET NUMBER

CASE NAME

Clerk of Courts

County

COURT NAME & ADDRESS

KEEPER OF RECORDS FOR HOSPITAL/CLINIC/HEALTH CARE FACILITY:

Pursuant to G.L. c. 111,§70, as amended, and in accordance with Superior Court Rule 13, it is hereby ORDERED that 

the keeper of records at the above named hospital, clinic, or health care facility, permit:  

 

to inspect the records concerning or relating to: 

(D.O.B.)

and to furnish to said attorney(s) or party, certified or attested copies of said records upon the payment of a reasonable fee. 

TIME FRAME:  The records shall include only documents created or dated 5 or fewer years before the date of this order 
unless another time frame appears here:

EXCEPTIONS:  This order does not authorize or require production of any records of the following, unless expressly ordered 
by the Court:

a. The following subject matters protected by specific statute: HIV or AIDS (G.L. c. 111, § 70F); venereal disease (G.L. c. 111,
§ 119); alcoholism treatment, drug rehabilitation, and federally conducted, regulated or assisted substance abuse treatment
(G.L. c. 111B, § 11, c. 111E, § 18; 42 U.S.C. §§ 290dd-2, 290ee-3);  emergency treatment of minors and reports concerning
suspected abuse, neglect, or injury to minors (G.L. c. 112, § 12F, c. 119, § 51A-E); domestic violence counseling (G.L. c. 233,
§ 20K);  patient records for persons committed for treatment in mental health facilities (G.L. c. 123 § 36); court records
concerning a minor's abortion (G.L. c. 112, § 12S), genetic tests, reports, and records (G.L. c. 111, § 70G); and Mammograms
(films), reports, and other related medical records (105 Code of Mass. Regs. § 127.020);  and treatment of rape or sexual
assault victims (G.L. c. 112, §12A ½ ).

b. Confidential communications with any or all of the following - licensed psychologists, licensed social workers, domestic
violence counselors, allied mental health or human services professionals, licensed mental health counselors, clergymen,
psychotherapists, or sexual assault counselors (G.L. c. 112, §§129A, 135A, 135B, 172, 172A; G.L. c. 233, §§20A, 20B, 20J).

 It is further ORDERED that the parties are hereby prohibited from using or disclosing the records produced 

hereunder for any purpose other than this litigation, and that the documents provided pursuant to this order are destroyed 
upon completion of this action or any subsequent appeal. 

DATE ISSUED

JUDGE

CLERK OF COURTS/ ASST. CLERK

X

Date/Time Printed:  07-28-2022 13:33:48 

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