Medical Records Release/request Form


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.;
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:
: 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
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.
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


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