hartford healthcare release of information form

To get or send a copy of your medical records, diagnostic imaging (x-ray, CT scan, MRI) CD’s, or pathology slides, fill out the Release of Medical Information Form on the other side of this page. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Author: Rachel Nosowsky Download and print the appropriate Authorization for Release of Health Information form in PDF. Contact the Medical Records Department. Click on Complete Request below to submit an online release of information authorization. Forms. If you have any questions regarding release of health information, please call (724) 983-3835. Salary Payment Option. By Paper Form. Teachers' Retirement. Use the Patient Health Information Access Request Form ; Write a letter. Complete all fields of the authorization form to prevent any delays in processing. A general authorization for the release of medical information … Please contact your provider's office for more information. Hartford Life and Accident Insurance Company (“The Hartford” or “we”) is committed to protecting the privacy of your health information. consent, or as otherwise permitted by such rules and statutes. Social Security Waiver. Form Revised: 1/2018 201177375_2 LAW AUTHORIZATION TO RELEASE INFORMATION LAST NAME MIDDLE NAME FIRST NAME ALL FORMER NAMES (Maiden, Alias, etc.) Protected Health Information form and letter of testamentary or a letter of administration from a Probate Court. Please complete all sections of the Authorization for Disclosure of Health Information Form. Contact Health Information Management. Resources and forms for new patients using select services with HonorHealth are provided below. You can access your inpatient medical information online through our patient portal. EASTERN CONNECTICUT MEDICAL PROFESSIONALS 71 Haynes Street, Manchester, CT 06040 Page 1 of 2 ROI AUTH-03/2017 AUTHORIZATION TO RELEASE OR OBTAIN HEALTH INFORMATION No part of this authorization is a required field. Professional Growth Form. Leave of Absence. Medical Records & Release Forms. FMLA Summary. Address: 100 Grand Street, New Britain, CT 06052 Phone: 860.224.5686 Hours: Mon-Fri, 8am to 4pm Be specific as you can about the type of information that you would like released (e.g. SHS Phone: 860.486.4700. Obtaining your personal health information is your right. Instructions for Completing the Authorization for Disclosure of Health Information Form. status@ recordconnectinc. Norton Healthcare is simplifying this process by allowing you to submit your request online. Authorization for Release of Protected Health Information _____ Patient’s Name Date of Birth Social Security Number I authorize the user or disclosure of my protected health information by Orthopedic Associates of Hartford, P.C., (“OAH”) as specified below. If you agree to sign this authorization to release or obtain information you will be given a copy of the signed form, upon request A separate signed authorization form is required for the use and disclosure of health information for: Psychotherapy notes Employment-related determinations by an employer Request a copy of your medical records. Personal Data Form. Plate: Black\r. Patient’s Name (Please Print) Name (If different) at time of visit(s) or treatment(s): 10/16) Please read instructions on reverse. In these unprecedented times, we are first and foremost committed to the health and wellbeing of our patients, staff and community. Hartford, CT 06156-9998 Please provide a copy of this form to your authorized representative so that they will be able to establish the validity of their request for your health information. roedter W ospital 3200 Pleasant Valley Road West Bend, WI 53095 Ph: 262-836-2510 x Fax: 262-836-8490 Froedter ospital 9200 West Wisconsin Avenue Milwaukee, WI 53226-3596 Ph: 414-805-2909 Fax: 414-259-1244 Release of Medical information Request How can I get my records? Download and fill out the Release of Information form as completely as you can. In most cases patients 18 years or older must sign their own authorization unless a legal guardian has been established by the court or their Health Care Proxy has been invoked. Here you will find frequently asked questions as well as the necessary medical record request forms to download. We are offering in-person and Telemedicine visits to provide health consultations by video and telephone. 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