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Uconn Health Record Release

Patient Request to Access Medical Records

Information Requested (Please check appropriate boxes below):
I authorize disclosure of the following (please check}:
Format Requested:
Requested Delivery Method:

*Health information transmitted via unencrypted email is not secure. I understand and accept that there are risks associated with transmitting my health information using unencrypted electronic formats, Including access by an unintended third party. If I request that UConn Health provide my health Information in an unencrypted format, UConn Health ls not responsible for unauthorized access of my health information while in transit. Further, UConn Health Is not responsible for safeguarding my information once delivered.

•• If you want to view or inspect your information, you must schedule an appointment to review ONLY the Information specified.

To schedule an appointment to review your Medical/Dental Records, please call: 860-679-3577

To schedule an appointment to review your Dental X-rays, please call: 860-679-2838

Information to Be Released to:

I understand that I will receive a copy of this Form and that my request will be processed within thirty (30) days.

I understand that if I checked the "Paper Copy" box above, I may be responsible for paying a reasonable cost-based fee for supplies, labor, postage and/or copying in accordance with HIPAA and that the requested information will be mailed to me via US postal mail at the address indicated above.

For Disclosures to Third Parties Only:

If this disclosure contains information relating to HIV, behavioral health, alcohol, drug and/or substance abuse treatment, the following shall apply: This information has been disclosed to you from records whose confidentiality is protected by law. Federal regulations (Title 42 CFR Part 2) and Connecticut General Statutes (Ch. 368x) prohibit 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 such regulations.

Return completed form via mail, fax or email to:

For Medical/Dental Records:

Mailing Address: 

 UConn Health
Health Information Management
Release of Information MC2260
263 Farmington Ave
Farmington, CT 06030


ROI Office Fax No.:  860-679-1273

Email: [email protected]



For Dental X-rays:

Mailing Address: 

UConn Health Dental
Medical Records
MC2105
263 Farmington Ave
Farmington, CT 06030

Office Fax No.: 860-679-7817

Email: [email protected]

Relationship to Patient:

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

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1:00 pm-6:00 pm

Tuesday:

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1:00 pm-6:00 pm

Wednesday:

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1:00 pm-6:00 pm

Thursday:

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Friday:

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Saturday:

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Sunday:

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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