Request for Records of Medical Records Form

I/We authorize and request that: Connecticut Asthma & Allergy Center

If Other, please specify:

and I understand the information released may include Psychiatric/Drug/Alcohol/HIV/AIDS information from the medical record of:

Patient's First Name:

Patient's Last Name:

Please forward to:

Name:

Phone Number:

Address:

Street:

City:

State:

Zip:

DISCLAIMER: By typing your name below, you are signing this application electronically and verifying that you are the patient. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name:

Date:

Patient Address:

Street:

City:

State:

Zip:

Patient Phone #:

Patient Date of Birth:

If patient is a minor child, please complete both parents’ signatures (or guardian signature) below.

DISCLAIMER: By typing your name below, you are signing this application electronically and verifying that you are the patient's parent or guardian. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

(Mother)

Date:

(Father)

Date:

(Legal guardian)

Date:

(Proof of guardianship must be submitted with request.)

Add file

Please upload a file

The confidentiality of this record is protected by the Federal Confidentiality Regulations 42 CFR 9 part 2 and chapter 899c of the Connecticut General Statues. This information shall not be transmitted to anyone else without written consent or other Authorization as provided in the statutes. I may revoke this authorization at any time, except to the extent that action has been taken in reliance upon it.

Forms are handled on a first-come-first-served basis. The turn around time is 2-4 weeks. Please do not call after filling out the forms as this will create a duplicate request. Thank you.

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