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Starling-Record Release

AUTHORIZATION TO RELEASE MEDICAL RECORDS

By signing this form, I (the patient or legal representative) authorize Starling Physicians to either send/ obtain a copy of my (or my child's) medical records.

Send records from:

Send records to:

Relationship to patient:
I authorize the following PHI (Protected Health Information) be sent for the sole purpose of: (Select option below)

*For transfers of care, I understand that my patient/physician relationship will be terminated 30 days from the date of my signature and that I will no longer be considered an active patient.


The dates of service and type(s) of information to be disclosed shall include: (please check the appropriate boxes below)
Include only the following specified information/records from the medical record:
Dates of treatment covered by this release:
I understand that state law prohibits the use and/or disclosure of the following types of PHI below without specific authorization by me. I indicate my authorization to release this information by initialing next to each option selected below:

I may cancel my permission at any time by writing a letter to cancel this permission or signing the cancellation below and sending it to Starling Physicians PC, Attention: Privacy Officer at 2110 Silas Deane Highway, Rocky Hill, CT. I understand that Starling Physicians, PC may have already sent my records prior to receiving my cancellation. Further, I understand that my medical treatment will not be affected if I do not sign this form. I understand that I may look at my medical records or receive a copy before they are sent. I further understand that this consent does not protect my personal health information from being disclosed by the receiving party. According to state law, I will be charged a copy fee of .65¢ per page when applicable. My signature below indicates that I have read and understand this Authorization and its terms.

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

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Office Hours

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