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Yale Health Record Release

Authorization for Access/Release of Information

This information is to be used for the purpose of:

If medical records are being requested from an external provider/facility for patient care at YNHHS, please provide name of YNHHS location to send medical information:

Method of Disclosure:
Visit Type:
Medical Information Requested:

***HIV-BEHAVIORAL HEALTH- DRUG/ALCOHOL INFORMATION contained within the medical records indicated above will be released through this authorization unless otherwise indicated below. (Medical records containing any of the protected information below must also be signed by the patient if a minor age 13 or older, with the exception of Behavioral Health, which also requires authorization by the patient if a minor age 16 or older.)***

Indicate which you do NOT want released with your initials:

I understand that:

• This authorization is valid for one year from the date below. I understand that after I have signed this form, I may change my mind and cancel (revoke) this authorization at any time by contacting in writing YNHHS Release of Information Services. Cancellation of the authorization will not apply to information that has already been released based on this authorization.

• The information disclosed in response to this authorization may be subject to re-disclosure by recipient, and will no longer be protected under the terms of this authorization or by federal privacy regulations. However, other state or federal law may prohibit the recipient from disclosing specially protected information such as substance abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information.

• That this authorization is voluntary and my treatment by YNHHS/Yale Medicine is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. If I do not sign this form, payment for this care will only be affected if my health care insurer is requesting this information and is permitted to require this authorization.

• On request, I may review or have copied the information described on this form if I ask for it. There may be a charge for copies in accordance with Connecticut law.

• The parent or legal guardian must sign this authorization if the patient is a minor (under age 18) unless the records relate to treatment(s) for which the minor may provide consent under CT state law. If HIV, Behavioral Health, Drug/Alcohol information is included for a patient age 13 or older, the minor must sign as described above.

Return completed authorization by mail, fax, or email as designated below. Do not send medical records to this address.
Mailing Address: 

Yale New Haven Health

Health Information Management
Release of Information Services
PO Box 9565
New Haven, CT 06535

YNHHS Hospital(s) Fax Number: 203-688-4645

Email to: [email protected]

NEMG Provider Fax Number: 203-200-1286

Email to: [email protected]

YM Provider Fax Number: 203-200-1287

Email to: [email protected]

Routine requests for medical records are generally processed within 10 business days. To contact a Customer Service Representative, please call 203-688-2231 .

Please check 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:

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:

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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