Forms and some of the reports are available in ADOBE ACROBAT (PDF) format. You do not have to sign this form. Part 2) restrict any use of the information to criminally investigate or prosecute any alcohol Norton Healthcare is simplifying this process by allowing you to submit your request online. Form Revised: 1/2018 201177375_2 LAW AUTHORIZATION TO RELEASE INFORMATION LAST NAME MIDDLE NAME FIRST NAME ALL FORMER NAMES (Maiden, Alias, etc.) Social Security Waiver. Complete all fields of the authorization form to prevent any delays in processing. 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. Be specific as you can about the type of information that you would like released (e.g. Obtaining your personal health information is your right. Individual Authorization for Release of Information Note: This form cannot be used for the authorization to release psychotherapy notes. Leave of Absence. 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. 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. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Author: Rachel Nosowsky Medical Records & Release Forms. Once submitted, your request will be processed within 14 business days. In these unprecedented times, we are first and foremost committed to the health and wellbeing of our patients, staff and community. 10/16) Please read instructions on reverse. Please complete all sections of the Authorization for Disclosure of Health Information Form. Contact Health Information Management. com or by fax to 1−630−873−8797. I understand that a general authorization for the release of medical or other information is NOT sufficient for release of these types of records. The signed and completed form can be returned to the Medical Record Department/Health Information Department either by fax, email, or general postal mail. Personal Data Form. If you have any questions regarding completing this form or release of information in general, contact us at 860-679-2787. FMLA Summary. 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. Use the Patient Health Information Access Request Form ; Write a letter. Dartmouth-Hitchcock keeps a private, secure medical record about your health. By Paper Form. Professional Growth Form. Regulations 42 CFR, part 2. Plate: Black\r. OR Fax form to: 724-983-3978 Attention: Release of Information. 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. Request Your Medical Records. Salary Payment Option. consent, or as otherwise permitted by such rules and statutes. Authorization Form to Use and/or Disclose Protected Health Information (PHI) PLEASE READ THIS DOCUMENT CAREFULLY. New Britain General & Bradley Memorial. 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 . Submit your completed paper authorization form to Record Connect by emailing a copy to dupage. This authorization form permits the University of Hartford Welfare Benefit Plan (the Plan) to Our offices are open. 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 ... Hartford, WI 53027 Ph: 262-836-2510 Fax: 262-836-8490. Resources and forms for new patients using select services with HonorHealth are provided below. I9. If you would like a copy of your records, you will need to download and sign an Authorization for Release of Records.. CentraCare (PDF) CentraCare - Monticello (PDF) Midsota Plastic Surgeons (PDF) (320) 200-3200. Sick Day Verification. Download and fill out the Release of Information form as completely as you can. You can then mail or fax the form to the Medical Records Department. Choose this option if you need to get medical records related to behavioral or mental health care services. 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. Therefore: If any of my records contain information about alcohol or … Get VA Form 10-5345, Request for and Authorization to Release Health Information. 1. Sensitive information regarding HIV/AIDS, or treatment for substance abuse (alcoholism or drug abuse) and/or mental health issues may be disclosed. As a patient with HonorHealth, you’ll be treated with care and compassion during your experience. In addition, Federal rules (42 C.F.R. Be sure to include both the name and address that you would like your records released to. Instructions for Completing the Authorization for Disclosure of Health Information Form. You can: Review the information in your medical records. Release of Medical information Request How can I get my records? If you have any questions regarding release of health information, please call (724) 983-3835. Download a PDF of the Slocum Dickson Medical Group Patient Release Form. Download a PDF of the Slocum Dickson Medical Group Patient Release Form. SHS Phone: 860.486.4700. Download and print the appropriate Authorization for Release of Health Information form in PDF. We are offering in-person and Telemedicine visits to provide health consultations by video and telephone. Release of Information Form. 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. Contact the Medical Records Department. Authoriation for Disclosure of ORIGINAL - Medical Records Protected Health Information - Form # 37976 CANARY - Patient 04/20 S oseph’ W nc. 4956NS.1016. Contact Us Patient Portal Pay Bills Online. specific dates of service, specific treatment, just your immunizations, etc). 1406 Sixth Avenue North St. Request a copy of your medical records. Hartford Life and Accident Insurance Company (“The Hartford” or “we”) is committed to protecting the privacy of your health information. Fingerprinting. 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 Address: 100 Grand Street, New Britain, CT 06052 Phone: 860.224.5686 Hours: Mon-Fri, 8am to 4pm 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 You may request a copy of your medical records at any time, but all requests must be in writing. Patient’s Name (Please Print) Name (If different) at time of visit(s) or treatment(s): AUTHORIZATION & FAX TRANSMITTAL TO RELEASE PERSONAL HEALTH INFORMATION . Requests for records should be made by using the Authorization for Release of Information forms below. Professional Growth Tuition Reimbursement. Follow the instructions in the documents for completing and bringing the documents with you to your appointment. Unit 4011 Storrs, CT 06269-4011. We are also committed to keeping your healthcare information private. Protected Health Information form and letter of testamentary or a letter of administration from a Probate Court. Authorization to Disclose Health Information (HHC) (English) Please contact your provider's office for more information. If you prefer to complete a paper authorization form, please download and print the Authorization for Release of Health Information Form. Cloud, MN 56303 Map + Directions. This often involves a fee. At Saint Francis Hospital, it’s our job to keep you healthy. Use this form to ask ProHealth Physicians in Connecticut to send your medical records to an individual or facility. Click on Complete Request below to submit an online release of information authorization. 234 Glenbrook Rd. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Find a Provider – Services & Specialties. Forms. Teachers' Retirement. 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. status@ recordconnectinc. Employee Assistance Program. University of Connecticut Student Health Services (SHS) SHS Medical Records FAX: 860.486.5300 . Request that your medical records be released to someone else. 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. A general authorization for the release of medical information … DCF - Authorization for Release of Information for DCF CPS Search. I do not authorize the release of sensitive information regarding HIV/AIDS, or treatment for substance abuse and/or mental health. We are happy to provide our patients with their medical records at their request. You can access your inpatient medical information online through our patient portal. 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. Use this VA form to authorize VA to share your health information with a third-party individual or organization. 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