Hartford HealthCare Offices. If you cannot download the form, you can send an email or written request for your medical records indicating: patient name, date of birth, type of information you are requesting, information that cannot be disclosed, and/or who may receive this information. We can provide or release copies of medical records at the written request of patients or their authorized legal representatives. We are inviting entrepreneurs from across the world to evaluate proposed new technologies and products with our clinical experts. Authorization for Release of Information to a third-Party (a Non-UCLA Provider, Insurance Company, Attorney, etc.). Use this form to ask ProHealth Physicians in Connecticut to send your medical records to an individual or facility. (85 Seymour Street, Suite 505, Hartford, CT 06106-5524) ... authorization for the release of medical or other information is NOT sufficient for this purpose. Your medical records can be sent to anyone, including health care providers, employers or organizations. This form template authorizes your healthcare provider to release your private medical records to the parties you specify. Your Banner Health account allows you manage your care from any device so you can: view lab results, request medical records, book appointments, message a doctor’s office and access important documents. WWW.CONNECTICUTCHILDRENS.ORG . The Medical Records form is available online ( below ) or can be obtained by visiting the Health Information Management Department during normal business hours. If you have questions, please call 262-696-5844. In order to respect your right to the privacy and confidentiality of the information contained in our medical records, we ask that you complete the Authorization to Release Medical Records if you are requesting a copy of your medical record for any care provided by Hartford HealthCare Medical Group. To obtain a copy of a medical record from The MetroHealth System, download, complete, sign, and date the Authorization to Release Protected Health Information (or Autorización para Divulgar Información de Salud) and mail to the attention of the Health Information Services Department according to the address provided on the form. HH Forms 575064 R12-18 Printed by the Digital Print Center @ HH ... notifying Hartford Healthcare Medical Group. How can I obtain my medical records? Request medical records if you would like a copy of your records, you will need to download and sign an authorization for release of records. 10 Columbus Blvd, Hartford, CT 06106 • (860) 837-5780. phone • (860) 837-5785. fax . Backus Hospital includes a not-for-profit, 213-bed hospital in Norwich and numerous off-site locations, including several health centers and the Backus Outpatient Care Center. >>, The vaccine is here! %PDF-1.4 >>, Hartford HealthCare ha ampliado su capacidad de pruebas del COVID-19 y ubicaciones. Medical records for services provided at Manchester Memorial Hospital, Rockville General Hospital, ECHN Medical Group, Woodlake at Tolland (WAT) or Visiting Nurse & Health Services of Connecticut (VNHSC) facilities can be provided at the written request of patients or their authorized legal representative, such as a Power of Attorney (POA) or healthcare representative. Authorization for Release of Health Information - English Hartford HealthCare Medical Group is one of the largest practices in Connecticut with over 50 locations throughout Connecticut and over 450 physicians and advanced practitioners. HIPAA requires a properly completed and signed authorization release be given to the Health Information Management Department by the patient in order for the Hospital to release medical records. Charlotte Hungerford Hospital is a 109-bed, general acute care community hospital in Torrington, Connecticut, that serves as a regional health care resource for 100,000 residents of Litchfield County and Northwest Connecticut. <> (If authorization is signed by a Legal Representative, a copy of the appropriate documentation verifying the individual's authority must be provided with the authorization.) If you prefer to write a letter it must include your name, date of birth, phone number, specific information you are authorizing for release, and the person/organization authorized to receive the information along with their address. <>/OutputIntents[<>] /Metadata 264 0 R>> >>, How to obtain a copy of your Medical Records from. medical records and release of information. 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