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CCMC Record Release

Medical Records Request

10 Columbus Blvd, Hartford, CT 06106 - (860) 837-5780 Phone - (860)837-5785 Fax

WWW.CONNECTICUTCHILDRENS.ORG

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

I authorize Connecticut Children's and/or Connecticut Children's Specialty Group, Inc. to use and/or disclose my protected health information (PHI) as provided below. I understand that I may revoke this Authorization, but the revocation will not apply to information that has already been released in response to this authorization. The written revocation letter needs to be sent to the Health Information Management (HIM) Department of Connecticut Children's. I understand that my/my child's treatment is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. I understand that once the PHI listed below is used or disclosed as set forth in this Authorization, it may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.

Please note that each section of the form must be completed in its entirety. Failure to complete a section (including dates) may delay the processing of your request. Please print clearly.•• Photo Identification may be requested for signature verification purposes.**

FOR CONNECTICUT CHILDREN'S TO DISCLOSE RECORDS (OR) FOR CONNECTICUT CHILDREN'S TO OBTAIN RECORDS

I authorize Connecticut Children's to disclose health information to:

to disclose health information to:

Connecticut Children's

City, State, Zip:

282 Washington Street

Hartford, CT 06106

Method of Disclosure
The dates of service and the types of information to be used or disclosed are as follows: Date(s) of Service/Department Requested:
The purpose of this disclosure or use is:

STOP: I understand that state law prohibits use and/or disclosure of the PHI listed below unless specifically authorized by me. I understand that such information will not be used or disclosed in response to the above request unless I indicate my authorization by initialing below.

Check one:

Note: If Legal Guardian box is checked, documentation establishing guardianship must be provided or on record in order to comply with the above request.

Thank you for taking the time to fill out this form.

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Monday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Tuesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Thursday:

8:00 am-11:00 am

11:30 am-1:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Office Hours

Our Regular Schedule

Monday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Tuesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Thursday:

8:00 am-11:00 am

11:30 am-1:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed