Medical Records Release/request Form printable pdf download

499 Farmington Ave | Suite 220 | Farmington, CT 06032

Medical Records Release/Request Form

Patient Authorization for Use or Disclosure of Protected Health Information

As required by the Health Portability and Accountability Act of 1996 (HIPAA) and Connecticut Law, a practice may not use or

disclose your identifiable health information without your authorization except as provided in our Notice of Privacy Practices.

Your completion of this form means that you give permission for the uses and disclosure described below. Please review and

complete this form carefully. It may be invalid if not fully completed. You may wish to ask the person or entity you want to

receive your information to complete those sections detailing the information to be released, and the purposes for the disclosure.

Your Name (Print)

Date of Birth

Other name e.g.;

Telephone

(maiden)

City/

Address

State

Zip

Date(s) of Service

OR, the entire Medical Record

for Release

I hereby authorize this medical practice, ___________________________________________ to release my health

___

information to:

Progressive Women’s Health, 499 Farmington Avenue, Suite 220

Farmington, CT 06032

Phone (860)676-8111 Fax (860) 677-2693

OR ____ Other practice (include name, address, phone number):

_____________________________________________________________________________________

Reason for release: __Ob/Gyn Care OR other: __________________________________________

RESTRICTIONS: I understand that the recipient of this information may not use or disclose this information except for the

expressed purposes identified above, unless another authorization is obtained from me, or such use or disclosure is specifically

required or permitted by law.

I understand that my medical record may include information relating to sexually transmitted disease; acquired immunodeficiency

syndrome (AIDS); human immunodeficiency virus (HIV); behavioral/mental health services; and/or treatment for alcohol and/or

drug abuse. Initial all requested exclusions:

EXCLUSION(S)

: Alcohol/Drug _______, Behavior/Mental Health/Psychiatric ______, Sexually Transmitted Disease _______,

HIV/AIDS ______, Other ______; specify other exclusion _________________________________________________________

I understand that I have the right to request that services for which I have paid out-of-pocket, not be disclosed to my health plan.

This authorization is effective ___________________________ through _________________________ (dates must be specified

Signature: _____________________________ Print Name: ________________________________ Date: ________________

If this form is completed by someone other than the patient, please print name, address, and initial below to indicate

relationship

____________________________

Name:

Address: _________________________________________________________

Guardian: _______ Conservator: _______ Parent: _______ Patient’s Representative: ______

I understand that I have the right to receive a copy of this authorization

Refusal to Sign Authorization

I understand that by declining to sign this form my medical (health care) treatment and insurance benefits will not be affected,

however, my medical records CANNOT be released. I understand that I may revoke this authorization at any time by notifying

this medical practice in writing as described in the Notice of Privacy Practices. My revocation will not affect actions taken by this

medical practice prior to its receipt. I understand that, if the recipient of the information is not a health care provider or health plan

covered by HIPAA, the information used or disclosed as described above may be redisclosed by the recipient and no longer

protected by HIPAA. However, other State or Federal laws may prohibit the recipient from disclosing specially protected

information, such as abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information.

Signature:_____________________________________________

As referenced in section 20c (b), Connecticut General Statutes allow a charge of $.65 per page to copy medical records, plus the

shipping and handling or any conveyance fees this office is required to pay. Fees are payable in advance, by cash or credit card.

Rev. for Progressive Women’s Health 7/2016 UAS&LTT

A division of Physicians for Women’s Health

Approved 6/09

Medical Records Release/request Form

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