Department Of Public Health Petition Form (Page 4 of 4) in pdf

Department Of Public Health Petition Form Page 4

Department of Public Health

Petition Form

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH

CONSENT FOR RELEASE OF MEDICAL RECORDS

Petition No.

Birth Date:

_______________________

Patient’s Address:

___________________________________________________________

This is to certify that I hereby give my consent to, and authorize:

(Name of Person/Facility/Organization)

to release a copy of all information and medical records in their possession, including psychiatric, psychological,

alcohol and/or drug related treatment records consisting of but not limited to the following:

1. Presence in treatment (dates of admission and discharge).

2. Diagnosis, brief description of progress and prognosis.

3. Medical history and physical.

4. Intake sheet.

5. Psychosocial assessment.

6. Treatment plan.

7. Discharge summary.

8. Aftercare plan.

(Name of Patient)

to the Practitioner Licensing and Investigations Section, of the State of Connecticut Department of Public Health, 410

Capitol Avenue, MS# 12HSR, P.O. Box 340308, Hartford, CT 06134-0308. This information is to be used in connection

with any investigation or hearing conducted by the Department of Public Health in accordance with Connecticut General

Statutes §19a-14(a)(10) and (11). I understand that I may revoke this consent at any time by notifying the above authorized

person in writing, except to the extent that action has been taken in reliance on my consent. I understand that the medical

record to be released may contain information pertaining to psychiatric, drug and/or alcohol abuse diagnosis and treatment,

and may also contain confidential HIV (AIDS) related information. Please honor a mechanically reproduced copy of this

release. This authorization expires one year from the date of the last signature.

__________________________________

________________________

Signature of Patient or Legal Representative

Date Signed

__________________________________

Relationship to Patient

__________________________________

________________________

Signature of Witness

Date Signed

Department Of Public Health Petition Form Page 4