com or by fax to 1−630−873−8797. Patient’s Name (Please Print) Name (If different) at time of visit(s) or treatment(s): Form Revised: 1/2018 201177375_2 LAW AUTHORIZATION TO RELEASE INFORMATION LAST NAME MIDDLE NAME FIRST NAME ALL FORMER NAMES (Maiden, Alias, etc.) If you cannot download the form, you can send an email or written request for your medical records indicating: patient name, date of birth, type of information you are requesting, information that cannot be disclosed, and/or who may receive this information. Medical Records & Release Forms. 234 Glenbrook Rd. Cloud, MN 56303 Map + Directions. The signed and completed form can be returned to the Medical Record Department/Health Information Department either by fax, email, or general postal mail. Social Security Waiver. If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form. You can: Review the information in your medical records. Use the Patient Health Information Access Request Form ; Write a letter. All forms can be mailed to: Middlesex Health System 28 Crescent Street Middletown, CT 06457 Attn: Release of Information Unit. New patient forms. Authorization Form to Use and/or Disclose Protected Health Information (PHI) PLEASE READ THIS DOCUMENT CAREFULLY. We are also committed to keeping your healthcare information private. Find a Provider – Services & Specialties. Protected Health Information form and letter of testamentary or a letter of administration from a Probate Court. Windham Hospital Medical Records (M - F 8:00 AM to 3:30 PM) 112 Mansfield Ave., Willimantic, CT 06226 Get Directions >> Phone: 860.456.6743 Fax: 860.456.6885 ... Hartford, WI 53027 Ph: 262-836-2510 Fax: 262-836-8490. Leave of Absence. Salary Payment Option. Request a copy of your medical records. Resources and forms for new patients using select services with HonorHealth are provided below. 1406 Sixth Avenue North St. FMLA Form. If you have not yet installed ACROBAT READER on your computer, you must download and install a FREE ACROBAT READER from ADOBE SOFTWARE first in order to view or print PDF documents.. Adobe also provides resources for visually impaired users to facilitate the use of screen readers with PDF documents. In addition, Federal rules (42 C.F.R. Download and print the appropriate Authorization for Release of Health Information form in PDF. You do not have to sign this form. Click on Complete Request below to submit an online release of information authorization. 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 Please complete all sections of the Authorization for Disclosure of Health Information Form. Request that your medical records be released to someone else. Professional Growth Form. Get VA Form 10-5345, Request for and Authorization to Release Health Information. Download a PDF of the Slocum Dickson Medical Group Patient Release Form. Be specific as you can about the type of information that you would like released (e.g. Hartford Life and Accident Insurance Company (“The Hartford” or “we”) is committed to protecting the privacy of your health information. Contact Health Information Management. Request Your Medical Records. 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. Use this form to ask ProHealth Physicians in Connecticut to send your medical records to an individual or facility. If you have any questions regarding release of health information, please call (724) 983-3835. University of Connecticut Student Health Services (SHS) SHS Medical Records FAX: 860.486.5300 . In these unprecedented times, we are first and foremost committed to the health and wellbeing of our patients, staff and community. Download a PDF of the Slocum Dickson Medical Group Patient Release Form. Follow the instructions in the documents for completing and bringing the documents with you to your appointment. 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. We are happy to provide our patients with their medical records at their request. Contact Us Patient Portal Pay Bills Online. Sub­mit your com­plet­ed paper autho­riza­tion form to Record Con­nect by email­ing a copy to dupage. Authorization to Disclose Health Information (HHC) (English) AUTHORIZATION & FAX TRANSMITTAL TO RELEASE PERSONAL HEALTH INFORMATION . Authorization to Release Health Information FORM 4956-NS (REV. Forms. Personal Data Form. This authorization form permits the University of Hartford Welfare Benefit Plan (the Plan) to status@ recordconnectinc. Download and fill out the Release of Information form as completely as you can. I do not authorize the release of sensitive information regarding HIV/AIDS, or treatment for substance abuse and/or mental health. Regulations 42 CFR, part 2. 4956NS.1016. You may request a copy of your medical records at any time, but all requests must be in writing. I9. Our offices are open. This information shall not be re-disclosed to anyone else without written consent or other authorization as provided in the Connecticut General Statutes and/or Federal Regulation 42 CFR, part 2. New Britain General & Bradley Memorial. Individual Authorization for Release of Information Note: This form cannot be used for the authorization to release psychotherapy notes. Social security numbers for newborns Please contact the Social Security Department in Willimantic, CT to inquire about social security numbers for newborns at 860.423.6386 . SHS Phone: 860.486.4700. You can then mail or fax the form to the Medical Records Department. Sensitive information regarding HIV/AIDS, or treatment for substance abuse (alcoholism or drug abuse) and/or mental health issues may be disclosed. If you would like a copy of your records, you will need to download and sign an Authorization for Release of Records.. This often involves a fee. Choose this option if you need to get medical records related to behavioral or mental health care services. Requests for records should be made by using the Authorization for Release of Information forms below. A general authorization for the release of medical information … Release of Information Form. In most cases patients 18 years or older must sign their own authorization unless a legal guardian has been established by the court or their Health Care Proxy has been invoked. Release of Medical information Request How can I get my records? You can access your inpatient medical information online through our patient portal. OR Bring form to: Sharon Regional Medical Center Health Information Management (Medical Records) 740 East State Street Sharon, PA 16146 Hours: Monday-Friday, 8:00 a.m. - 4:30 p.m. 1. CentraCare (PDF) CentraCare - Monticello (PDF) Midsota Plastic Surgeons (PDF) (320) 200-3200. Contact the Medical Records Department. A general authorization for the release of medical or other information is NOT sufficient for this purpose. I understand that a general authorization for the release of medical or other information is NOT sufficient for release of these types of records. Address: 100 Grand Street, New Britain, CT 06052 Phone: 860.224.5686 Hours: Mon-Fri, 8am to 4pm Use this VA form to authorize VA to share your health information with a third-party individual or organization. OR Fax form to: 724-983-3978 Attention: Release of Information. Dartmouth-Hitchcock keeps a private, secure medical record about your health. Sick Day Verification. Fingerprinting. Authorization for Release of Protected Health Information _____ Patient’s Name Date of Birth Social Security Number I authorize the user or disclosure of my protected health information by Orthopedic Associates of Hartford, P.C., (“OAH”) as specified below. Professional Growth Tuition Reimbursement. FMLA Summary. Teachers' Retirement. 10/16) Please read instructions on reverse. Authoriation for Disclosure of ORIGINAL - Medical Records Protected Health Information - Form # 37976 CANARY - Patient 04/20 S oseph’ W nc. Therefore: If any of my records contain information about alcohol or … We are offering in-person and Telemedicine visits to provide health consultations by video and telephone. Here you will find frequently asked questions as well as the necessary medical record request forms to download. Be sure to include both the name and address that you would like your records released to. specific dates of service, specific treatment, just your immunizations, etc). If you have any questions regarding completing this form or release of information in general, contact us at 860-679-2787. Please contact your provider's office for more information. Employee Assistance Program. Instructions for Completing the Authorization for Disclosure of Health Information Form. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Author: Rachel Nosowsky As a patient with HonorHealth, you’ll be treated with care and compassion during your experience. Part 2) restrict any use of the information to criminally investigate or prosecute any alcohol If you don’t want to complete one of the forms listed above, you can write us a letter requesting the release of your health information. Norton Healthcare is simplifying this process by allowing you to submit your request online. Complete all fields of the authorization form to prevent any delays in processing. By Paper Form. Plate: Black\r. Forms and some of the reports are available in ADOBE ACROBAT (PDF) format. If you agree to sign this authorization to release or obtain information you will be given a copy of the signed form, upon request A separate signed authorization form is required for the use and disclosure of health information for: Psychotherapy notes Employment-related determinations by an employer , CT 06457 Attn: Release of information for dcf CPS Search with you to your.. 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