All forms can be mailed to: Middlesex Health System 28 Crescent Street Middletown, CT 06457 Attn: Release of Information Unit. Patient’s Name (Please Print) Name (If different) at time of visit(s) or treatment(s): 234 Glenbrook Rd. Be sure to include both the name and address that you would like your records released to. If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form. DCF - Authorization for Release of Information for DCF CPS Search. Professional Growth Form. Employee Assistance Program. Personal Data Form. Form Revised: 1/2018 201177375_2 LAW AUTHORIZATION TO RELEASE INFORMATION LAST NAME MIDDLE NAME FIRST NAME ALL FORMER NAMES (Maiden, Alias, etc.) Instructions for Completing the Authorization for Disclosure of Health Information Form. We are happy to provide our patients with their medical records at their request. Salary Payment Option. Please contact your provider's office for more information. Once submitted, your request will be processed within 14 business days. This authorization form permits the University of Hartford Welfare Benefit Plan (the Plan) to 4956NS.1016. 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. ... Hartford, WI 53027 Ph: 262-836-2510 Fax: 262-836-8490. I9. 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. You can: Review the information in your medical records. 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. SHS Phone: 860.486.4700. Follow the instructions in the documents for completing and bringing the documents with you to your appointment. Authorization Form to Use and/or Disclose Protected Health Information (PHI) PLEASE READ THIS DOCUMENT CAREFULLY. This often involves a fee. Professional Growth Tuition Reimbursement. 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 Our offices are open. We are offering in-person and Telemedicine visits to provide health consultations by video and telephone. 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. Please complete all sections of the Authorization for Disclosure of Health Information Form. Use this VA form to authorize VA to share your health information with a third-party individual or organization. Download a PDF of the Slocum Dickson Medical Group Patient Release Form. Authorization to Disclose Health Information (HHC) (English) OR Fax form to: 724-983-3978 Attention: Release of Information. Download a PDF of the Slocum Dickson Medical Group Patient Release Form. New patient forms. A general authorization for the release of medical or other information is NOT sufficient for this purpose. 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 . By Paper Form. Forms and some of the reports are available in ADOBE ACROBAT (PDF) format. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Author: Rachel Nosowsky Click on Complete Request below to submit an online release of information authorization. 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. Forms. Cloud, MN 56303 Map + Directions. com or by fax to 1−630−873−8797. Get VA Form 10-5345, Request for and Authorization to Release Health Information. Request that your medical records be released to someone else. Request a copy of your medical records. status@ recordconnectinc. A general authorization for the release of medical information … In addition, Federal rules (42 C.F.R. 1. FMLA Form. Norton Healthcare is simplifying this process by allowing you to submit your request online. 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. 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 Be specific as you can about the type of information that you would like released (e.g. 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. 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. Request Your Medical Records. Authoriation for Disclosure of ORIGINAL - Medical Records Protected Health Information - Form # 37976 CANARY - Patient 04/20 S oseph’ W nc. Contact Us Patient Portal Pay Bills Online. Social Security Waiver. At Saint Francis Hospital, it’s our job to keep you healthy. 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 Contact the Medical Records Department. The signed and completed form can be returned to the Medical Record Department/Health Information Department either by fax, email, or general postal mail. AUTHORIZATION & FAX TRANSMITTAL TO RELEASE PERSONAL HEALTH INFORMATION . 10/16) Please read instructions on reverse. Unit 4011 Storrs, CT 06269-4011. Authorization to Release Health Information FORM 4956-NS (REV. 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