Request for Records of Medical Records Form

Please correct the errors described below.

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

Please forward to:

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.

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.

    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.

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