Employee Assistance Program. Protected Health Information form and letter of testamentary or a letter of administration from a Probate Court. We are offering in-person and Telemedicine visits to provide health consultations by video and telephone. Request Your Medical Records. You can then mail or fax the form to the Medical Records Department. Please complete all sections of the Authorization for Disclosure of Health Information Form. Authorization to Disclose Health Information (HHC) (English) Download and fill out the Release of Information form as completely as you can. Choose this option if you need to get medical records related to behavioral or mental health care services. Leave of Absence. Professional Growth Tuition Reimbursement. Authorization to Release Health Information FORM 4956-NS (REV. 1406 Sixth Avenue North St. You can access your inpatient medical information online through our patient portal. Release of Medical information Request How can I get my records? Complete all fields of the authorization form to prevent any delays in processing. ... Hartford, WI 53027 Ph: 262-836-2510 Fax: 262-836-8490. Teachers' Retirement. 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 . Instructions for Completing the Authorization for Disclosure of Health Information Form. Download and print the appropriate Authorization for Release of Health Information form in PDF. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Author: Rachel Nosowsky We are happy to provide our patients with their medical records at their request. Sub­mit your com­plet­ed paper autho­riza­tion form to Record Con­nect by email­ing a copy to dupage. We are also committed to keeping your healthcare information private. Our offices are open. 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. 1. Request that your medical records be released to someone else. Find a Provider – Services & Specialties. specific dates of service, specific treatment, just your immunizations, etc). Medical Records & Release Forms. Contact Us Patient Portal Pay Bills Online. 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. 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. At Saint Francis Hospital, it’s our job to keep you healthy. I understand that a general authorization for the release of medical or other information is NOT sufficient for release of these types of records. SHS Phone: 860.486.4700. I do not authorize the release of sensitive information regarding HIV/AIDS, or treatment for substance abuse and/or mental health. Here you will find frequently asked questions as well as the necessary medical record request forms to download. All forms can be mailed to: Middlesex Health System 28 Crescent Street Middletown, CT 06457 Attn: Release of Information Unit. The signed and completed form can be returned to the Medical Record Department/Health Information Department either by fax, email, or general postal mail. Address: 100 Grand Street, New Britain, CT 06052 Phone: 860.224.5686 Hours: Mon-Fri, 8am to 4pm 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. 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 You may request a copy of your medical records at any time, but all requests must be in writing. Professional Growth Form. 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 Forms. Plate: Black\r. Please contact your provider's office for more information. Once submitted, your request will be processed within 14 business days. I9. consent, or as otherwise permitted by such rules and statutes. OR Fax form to: 724-983-3978 Attention: Release of Information. 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 Therefore: If any of my records contain information about alcohol or … Salary Payment Option. By Paper Form. Use this VA form to authorize VA to share your health information with a third-party individual or organization. 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. 10/16) Please read instructions on reverse. 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 com or by fax to 1−630−873−8797. Regulations 42 CFR, part 2. Obtaining your personal health information is your right. Request a copy of your medical records. Use this form to ask ProHealth Physicians in Connecticut to send your medical records to an individual or facility. Forms and some of the reports are available in ADOBE ACROBAT (PDF) format. Hartford Life and Accident Insurance Company (“The Hartford” or “we”) is committed to protecting the privacy of your health information. Be specific as you can about the type of information that you would like released (e.g. Dartmouth-Hitchcock keeps a private, secure medical record about your health. University of Connecticut Student Health Services (SHS) SHS Medical Records FAX: 860.486.5300 . New Britain General & Bradley Memorial. 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. 4956NS.1016. A general authorization for the release of medical information … If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form. Sick Day Verification. Social Security Waiver. A general authorization for the release of medical or other information is NOT sufficient for this purpose. 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. New patient forms. If you have any questions regarding release of health information, please call (724) 983-3835. This authorization form permits the University of Hartford Welfare Benefit Plan (the Plan) to 234 Glenbrook Rd. FMLA Form. Download a PDF of the Slocum Dickson Medical Group Patient Release Form. If you would like a copy of your records, you will need to download and sign an Authorization for Release of Records.. Fingerprinting. This often involves a fee. Use the Patient Health Information Access Request Form ; Write a letter. Individual Authorization for Release of Information Note: This form cannot be used for the authorization to release psychotherapy notes. Sensitive information regarding HIV/AIDS, or treatment for substance abuse (alcoholism or drug abuse) and/or mental health issues may be disclosed. Patient’s Name (Please Print) Name (If different) at time of visit(s) or treatment(s): Download a PDF of the Slocum Dickson Medical Group Patient Release Form. 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. 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 Information Form. FMLA Summary. Authorization Form to Use and/or Disclose Protected Health Information (PHI) PLEASE READ THIS DOCUMENT CAREFULLY. Norton Healthcare is simplifying this process by allowing you to submit your request online. Contact Health Information Management. Follow the instructions in the documents for completing and bringing the documents with you to your appointment. In these unprecedented times, we are first and foremost committed to the health and wellbeing of our patients, staff and community. Get VA Form 10-5345, Request for and Authorization to Release Health Information. If you have any questions regarding completing this form or release of information in general, contact us at 860-679-2787. Contact the Medical Records Department. DCF - Authorization for Release of Information for DCF CPS Search. Unit 4011 Storrs, CT 06269-4011. In addition, Federal rules (42 C.F.R. Authoriation for Disclosure of ORIGINAL - Medical Records Protected Health Information - Form # 37976 CANARY - Patient 04/20 S oseph’ W nc. You can: Review the information in your medical records. CentraCare (PDF) CentraCare - Monticello (PDF) Midsota Plastic Surgeons (PDF) (320) 200-3200. Resources and forms for new patients using select services with HonorHealth are provided below. 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. You do not have to sign this form. Personal Data Form. As a patient with HonorHealth, you’ll be treated with care and compassion during your experience. Be sure to include both the name and address that you would like your records released to. AUTHORIZATION & FAX TRANSMITTAL TO RELEASE PERSONAL HEALTH INFORMATION . Requests for records should be made by using the Authorization for Release of Information forms below. status@ recordconnectinc. Click on Complete Request below to submit an online release of information authorization. Cloud, MN 56303 Map + Directions.