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Hartford Healthcare Record Release

AUTHORIZATION TO DISCLOSE/OBTAIN HEALTH INFORMATION

Subject to the statements printed on the back, I, the undersigned patient or legal representative, hereby authorize the use and disclosure of health information including, if applicable, information relating to the diagnosis or treatment of mental illness, drug and/or alcohol abuse and HIV related information.

FILL OUT BELOW TO DISCLOSE/OBTAIN

Method of Disclosure/obtain:
The dates of service and the type(s) of information to be used or disclosed are as follows:
Date(s) of Treatment or Date Range:
The purpose of this disclosure or use is for the following reason: (Optional)

If date is not completed, this authorization will expire one year from the date of signature below. I understand that I may revoke this authorization at any time by notifying Patient Relations in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization.

I understand that under applicable law, the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal privacy regulations.


I understand that my treatment or continued 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 I may inspect or copy the information to be used or disclosed


 Legal guardian must sign this authorization if the patient is a minor.


Minors receiving drug abuse, mental health, venereal disease treatment may sign their own authorization.

Authorization can be sent to:
Relationship to patient:

HIV RELATED INFORMATION 

In the event that information release constitutes confidential HIV related information protected under Connecticut Law: this information has been disclosed to you from records whose confidentiality is protected by state law. State law
prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

PSYCHIATRIC INFORMATION

If the event that information released constitutes confidential psychiatric information protected under Connecticut Law: This information has been disclosed to you from records whose confidentiality is protected by state law. State law
Prohibits you from making any further disclosure of it or of using it for any purpose other than that indicated above without The specific written consent by the person to whom it pertains, or as otherwise permitted by said law.

DRUG AND ALCOHOL ABUSE RECORDS

In the event that information released is protected by the HHS Confidentiality of Alcohol and Drug Abuse Patient Records Regulations:
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2}. The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly Permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general Authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict Any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

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:

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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