Form Revised: 1/2018 201177375_2 LAW AUTHORIZATION TO RELEASE INFORMATION LAST NAME MIDDLE NAME FIRST NAME ALL FORMER NAMES (Maiden, Alias, etc.) Release of Medical information Request How can I get my records? Use this form to ask ProHealth Physicians in Connecticut to send your medical records to an individual or facility. Address: 100 Grand Street, New Britain, CT 06052 Phone: 860.224.5686 Hours: Mon-Fri, 8am to 4pm Contact the Medical Records Department. OR Fax form to: 724-983-3978 Attention: Release of Information. Forms. Authorization to Release Health Information FORM 4956-NS (REV. Cloud, MN 56303 Map + Directions. Be specific as you can about the type of information that you would like released (e.g. Hartford, CT 06156-9998 Please provide a copy of this form to your authorized representative so that they will be able to establish the validity of their request for your health information. EASTERN CONNECTICUT MEDICAL PROFESSIONALS 71 Haynes Street, Manchester, CT 06040 Page 1 of 2 ROI AUTH-03/2017 AUTHORIZATION TO RELEASE OR OBTAIN HEALTH INFORMATION No part of this authorization is a required field. Part 2) restrict any use of the information to criminally investigate or prosecute any alcohol University of Connecticut Student Health Services (SHS) SHS Medical Records FAX: 860.486.5300 . Contact Health Information Management. Instructions for Completing the Authorization for Disclosure of Health Information Form. Request Your Medical Records. Fingerprinting. All forms can be mailed to: Middlesex Health System 28 Crescent Street Middletown, CT 06457 Attn: Release of Information Unit. Complete all fields of the authorization form to prevent any delays in processing. The signed and completed form can be returned to the Medical Record Department/Health Information Department either by fax, email, or general postal mail. roedter W ospital 3200 Pleasant Valley Road West Bend, WI 53095 Ph: 262-836-2510 x Fax: 262-836-8490 Froedter ospital 9200 West Wisconsin Avenue Milwaukee, WI 53226-3596 Ph: 414-805-2909 Fax: 414-259-1244 Sensitive information regarding HIV/AIDS, or treatment for substance abuse (alcoholism or drug abuse) and/or mental health issues may be disclosed. Plate: Black\r. Forms and some of the reports are available in ADOBE ACROBAT (PDF) format. Obtaining your personal health information is your right. You can: Review the information in your medical records. Please contact your provider's office for more information. If you would like a copy of your records, you will need to download and sign an Authorization for Release of Records.. This authorization form permits the University of Hartford Welfare Benefit Plan (the Plan) to To get or send a copy of your medical records, diagnostic imaging (x-ray, CT scan, MRI) CD’s, or pathology slides, fill out the Release of Medical Information Form on the other side of this page. I9. Be sure to include both the name and address that you would like your records released to. 1406 Sixth Avenue North St. Download a PDF of the Slocum Dickson Medical Group Patient Release Form. consent, or as otherwise permitted by such rules and statutes. Norton Healthcare is simplifying this process by allowing you to submit your request online. Requests for records should be made by using the Authorization for Release of Information forms below. Therefore: If any of my records contain information about alcohol or … We are also committed to keeping your healthcare information private. In addition, Federal rules (42 C.F.R. Resources and forms for new patients using select services with HonorHealth are provided below.

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