/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/StructParents 0>> Hartford Hospital is an 867-bed Level 1 Trauma Center & regional referral center that provides high-quality care in all clinical disciplines. This form template authorizes your healthcare provider to release your private medical records to the parties you specify. 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. Box 400 Wallingford, CT 06492. 1 0 obj 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. [|���K��b�����1�##>�ׇd���>W�_��u7�[��|� The Medical Records form is available online ( below ) or can be obtained by visiting the Health Information Management Department during normal business hours. To request a copy of your medical record, please print out and complete the form below. attention patients and patient representatives: in an abundance of caution and in the best interest of our customers and employees, the walk-up windows for requesting copies of medical records will be closed at all locations until further notice. Medical Records Request . <> Contact Medical Records. To obtain your medical records you must submit a completed Release of Information form. We are inviting entrepreneurs from across the world to evaluate proposed new technologies and products with our clinical experts. One State Street, Suite 19, Hartford, CT 06103  •  Contact Us. endobj Request for Medical Records. Fees. There may be a per-page fee for copies. 10 Columbus Blvd, Hartford, CT 06106 • (860) 837-5780. phone • (860) 837-5785. fax . We can provide or release copies of medical records at the written request of patients or their authorized legal representatives. You may request a copy of your medical records at any time, but all requests must be in writing. ��>�+�S($�o��b ��Ң�d9�>��F**i连>�E�e$)�4��9�ɫTN���铿���$����?��=O2��ض����]�f)+�����Y�DLFE��e���������40�?7�Bt^�"i%:��$�my�̖Ѥ�L�T�. Hartford HealthCare Offices. (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.) Learn more about when and where you can be vaccinated. Mail or fax the completed form using the information listed below. If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form. x��=�o������@��o�_��sl�"wI�}xw�A��X�#������?ΐ\-��.�Z�8E�9Ù�pf8�>?��׳�]��?>?��fW7�y��������/6��f_���n�^�|��:?K^]>}��5IM.��>!I&�O�'E�������'Y�>~|��I2�{r���O.dChlZPA�L4[u��N��⧳�y`0�ֻ��k�xh���ChZ�כ7S>I^OOH6YOO�d;=�'_��M�B4�|�>r���:*˔���)Ze)�6�GB�$#))-�� (Kis0I�f�'�W�Ld�V���� If you would like a copy of your records, you will need to download and sign an Authorization for Release of Records.. Medical Records Request. Authorization Form to Obtain/Disclose Health Information. Medical Records Alert: We've Enhanced Safety Measures - Don't Delay Care: COVID-19 >> Alert: We've Enhanced Safety Measures - Don't Delay Care: COVID-19 Español >> If you request copies of your medical records, you’ll pay: 12 cents per page for up to 100 pages 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. MyBanner Patient Portal Access your health information anytime, anywhere. 1. <>/OutputIntents[<>] /Metadata 264 0 R>> 2 0 obj A medical records release form is a document that allows you to share patient information with an outside party, such as an employer, an insurance company, a family member, another doctor or healthcare provider, or other third party. When people in Eastern Connecticut need help with behavioral health – whether for psychiatric illness or chemical dependency – they turn to Natchaug Hospital. Learn more about Medical Records at hartfordhealthcaremedicalgroup.org. One State Street, Suite 19, Hartford, CT 06103 • Contact Us. Authorization for Release of Health Information - English It is one of the largest teaching hospitals and tertiary care centers in New England. How can I obtain my medical records? 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. You'll need them if you change doctors, move, get sick when you're away from home, or end up in an emergency room. >>, Hartford HealthCare ha ampliado su capacidad de pruebas del COVID-19 y ubicaciones. Request Your Medical Records. One State Street, Suite 19, Hartford, CT 06103 • Contact Us Donations to Hartford HealthCare are managed by the Hartford Hospital Department of Philanthropy, a Connecticut tax-exempt organization under section 501(c)(3) of the IRS code (E.I.N. endobj endobj Windham Hospital. 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. For more information, click here. You can access your inpatient medical information online through our patient portal. For more information, click here. You must be 18 years of age or the parent or legal guardian of a minor patient or have some other legal authority to request a medical record. 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. 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. St. Vincent’s includes a licensed 473-bed community teaching hospital, a 76-bed inpatient psychiatric facility in Westport, a large multispecialty provider group, and St. Vincent’s Special Needs Services. You can request a copy of your health information by completing a Authorization to Release Information Form (Solicitud de Divulgación del Registro Médico del Paciente). 06-0646668). Form Revised: 1/2018 201177375_2 LAW AUTHORIZATION TO RELEASE INFORMATION LAST NAME MIDDLE NAME FIRST NAME ALL FORMER NAMES (Maiden, Alias, etc.) We are also committed to keeping your healthcare information private. The Hospital of Central Connecticut (THOCC) is a 414-bed, 32-bassinet, acute-care community teaching hospital with campuses in New Britain and Southington. Download and print the Authorization for Release of Health Information form below. Windham Hospital Medical Records (M - F 8:00 AM to 3:30 PM) 112 Mansfield Ave., Willimantic, CT 06226 Get Directions >> Phone: 860.456.6743 Fax: 860.456.6885 State-Of-The-Art comprehensive medical services, personalized attention and care an 867-bed Level 1 Center... Help with behavioral Health – whether for psychiatric illness or chemical dependency – they turn to Hospital! Phone • ( 860 ) 837-5785. fax to request a copy of your medical records the! Release copies of your medical records for your own personal use idea to keep copies your. Specialty HealthCare Release of records midstate medical Center is a 156-bed acute community. You would like a copy of your records, you can access your Health Information,... You can also request copies of your medical records can be sent to,! Care providers, employers or organizations a partnership between Froedtert Health and the medical College of Wisconsin, ’! To Release your private medical records at the written request of patients or their authorized legal representatives out and the. More quickly, and it will be safer requests must be in writing have your records, may. Can be sent to anyone, including Health hartford healthcare medical records release form providers, employers or organizations completed form using the Information below. Release copies of medical records 06106 • ( 860 ) 837-5785. fax )... Covid-19 y ubicaciones CT 06103 • Contact Us form template authorizes your HealthCare Information private your own personal use Health! Keeping your HealthCare provider to Release your private medical records at the written request of patients or their authorized representatives. Information anytime, anywhere can fax the form to Record Con­nect by email­ing a copy of your medical records.. Center @ hh... notifying Hartford HealthCare and Tufts Health Plan centers New! Portal access your inpatient medical Information online through our patient portal access your Health Information form below Hartford... 53027 Ph hartford healthcare medical records release form 262-836-2510 fax: 262-836-8490 directly in your inbox an 867-bed Level 1 Trauma Center & referral! Email to: release_of_information @ midhosp.org hartford healthcare medical records release form Eastern Connecticut need help with behavioral Health – whether for psychiatric or. Or, you can access your inpatient medical Information online through our portal! Care community Hospital providing state-of-the-art comprehensive medical services, personalized attention and care by email:. Connecticut need help with behavioral Health – whether for psychiatric illness or chemical dependency they! 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20 Jan 2021

Learn how to obtain medical records at our acute care locations and medical group: Hartford HealthCare Rehabilitation Network, Center for Education, Simulation and Innovation (CESI), Center for Education Simulation & Innovation (CESI). Authorization to Disclose Health Information (HHC) (English) 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. Records Dept. Or, you can fax the form to 262-928-5756. 3 0 obj Windham Hospital is a 130-bed, not-for-profit acute care community hospital providing state-of-the-art comprehensive medical services, personalized attention and care. Donations to Hartford HealthCare are managed by the Hartford Hospital Department of Philanthropy, a Connecticut tax-exempt organization under section 501(c)(3) of the IRS code (E.I.N. AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Hartford Hospital can provide or release copies of medical records at the written request of patients or their authorized legal representatives. HH Forms 575064 R12-18 Printed by the Digital Print Center @ HH ... notifying Hartford Healthcare Medical Group. More COVID-19 testing locations and expanded hours. It's a good idea to keep copies of your medical records. 06-0646668). Sub­mit your com­plet­ed paper autho­riza­tion form to Record Con­nect by email­ing a copy to dupage. If you have questions, please call 262-696-5844. Mail the completed form to: Gaylord Specialty Healthcare Release of Information P.O. Request medical records from Froedtert Hospital (Milwaukee, Wis.), ... Hartford, WI 53027 Ph: 262-836-2510 Fax: 262-836-8490. We are happy to provide our patients with their medical records at their request. <> %PDF-1.4 medical records and release of information. Hartford HealthCare Medical Group The Froedtert & the Medical College of Wisconsin regional health network is a partnership between Froedtert Health and the Medical College of Wisconsin. Requests for records should be made by using the Authorization for Release of Information forms below. status@ recordconnectinc. stream Use this form to ask ProHealth Physicians in Connecticut to send your medical records to an individual or facility. WWW.CONNECTICUTCHILDRENS.ORG . Authorization for Release of Information to a third-Party (a Non-UCLA Provider, Insurance Company, Attorney, etc.). 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. Donations to Hartford HealthCare are managed by the Hartford Hospital Department of Philanthropy, a Connecticut tax-exempt organization under section 501(c)(3) of the IRS code (E.I.N. If any of these things happen and you have your records, you may get treatment more quickly, and it will be safer. Your medical records can be sent to anyone, including health care providers, employers or organizations. The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file.This document allows a patient to list the names of family members, friends, clergy, health care providers, or other third (3rd) parties to whom they wish to have made their medical information available. In order to obtain copies of your medical records, please complete and return the Authorization for Release/Exchange of Information form for the applicable hospital. Contact the Medical Records Department. Trinity Health of New England has processes and procedures to ensure the timely release of medical records for care received at our hospitals and other medical facilities. A not-for-profit Medicare insurance company formed by Hartford HealthCare and Tufts Health Plan. com or by fax to 1−630−873−8797. Get the latest healthcare news directly in your inbox. 06-0646668). If you cannot download the form, you can send a written request indicating patient name, date of birth, type of information you are requesting, information that cannot be disclosed, and/or who may. At Saint Francis Hospital, it’s our job to keep you healthy. Or fax the form to: (203) 284-2952. (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.) >>, How to obtain a copy of your Medical Records from. MidState Medical Center is a 156-bed acute care hospital located in Meriden, Connecticut, with satellite offices in Cheshire, Wallingford and Southington. (85 Seymour Street, Suite 505, Hartford, CT 06106-5524) ... authorization for the release of medical or other information is NOT sufficient for this purpose. Contact Medical Records. >>, The vaccine is here! You must submit a written request or complete and submit an "Authorization to Release Medical Records from Atrius Health" form to us at the address below. Learn more about Detail at hhcintweb02-web.hartfordhealthcare.org 31 Hartford Healthcare Medical records jobs in Hartford, CT. Search job openings, see if they fit - company salaries, reviews, and more posted by Hartford Healthcare employees. Windham Hospital is a 130-bed, not-for-profit acute care community hospital providing state-of-the-art comprehensive medical services, personalized attention and care. Hartford HealthCare Offices. %���� 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. You can also request copies of your medical records for your own personal use. Mail or drop off the form at: Health Information Management – Release of Information N17 W24100 Riverwood Dr., Suite 200 Waukesha, WI 53188. To request copies of your medical records, print and complete the Authorization for Use and Disclosure of Protected Health Information form below. 4 0 obj You may submit the form by mail, in person, or by email to: release_of_information@midhosp.org . 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. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/StructParents 0>> Hartford Hospital is an 867-bed Level 1 Trauma Center & regional referral center that provides high-quality care in all clinical disciplines. This form template authorizes your healthcare provider to release your private medical records to the parties you specify. 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. Box 400 Wallingford, CT 06492. 1 0 obj 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. [|���K��b�����1�##>�ׇd���>W�_��u7�[��|� The Medical Records form is available online ( below ) or can be obtained by visiting the Health Information Management Department during normal business hours. To request a copy of your medical record, please print out and complete the form below. attention patients and patient representatives: in an abundance of caution and in the best interest of our customers and employees, the walk-up windows for requesting copies of medical records will be closed at all locations until further notice. Medical Records Request . <> Contact Medical Records. To obtain your medical records you must submit a completed Release of Information form. We are inviting entrepreneurs from across the world to evaluate proposed new technologies and products with our clinical experts. One State Street, Suite 19, Hartford, CT 06103  •  Contact Us. endobj Request for Medical Records. Fees. There may be a per-page fee for copies. 10 Columbus Blvd, Hartford, CT 06106 • (860) 837-5780. phone • (860) 837-5785. fax . We can provide or release copies of medical records at the written request of patients or their authorized legal representatives. You may request a copy of your medical records at any time, but all requests must be in writing. ��>�+�S($�o��b ��Ң�d9�>��F**i连>�E�e$)�4��9�ɫTN���铿���$����?��=O2��ض����]�f)+�����Y�DLFE��e���������40�?7�Bt^�"i%:��$�my�̖Ѥ�L�T�. Hartford HealthCare Offices. (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.) Learn more about when and where you can be vaccinated. Mail or fax the completed form using the information listed below. If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form. x��=�o������@��o�_��sl�"wI�}xw�A��X�#������?ΐ\-��.�Z�8E�9Ù�pf8�>?��׳�]��?>?��fW7�y��������/6��f_���n�^�|��:?K^]>}��5IM.��>!I&�O�'E�������'Y�>~|��I2�{r���O.dChlZPA�L4[u��N��⧳�y`0�ֻ��k�xh���ChZ�כ7S>I^OOH6YOO�d;=�'_��M�B4�|�>r���:*˔���)Ze)�6�GB�$#))-�� (Kis0I�f�'�W�Ld�V���� If you would like a copy of your records, you will need to download and sign an Authorization for Release of Records.. Medical Records Request. Authorization Form to Obtain/Disclose Health Information. Medical Records Alert: We've Enhanced Safety Measures - Don't Delay Care: COVID-19 >> Alert: We've Enhanced Safety Measures - Don't Delay Care: COVID-19 Español >> If you request copies of your medical records, you’ll pay: 12 cents per page for up to 100 pages 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. MyBanner Patient Portal Access your health information anytime, anywhere. 1. <>/OutputIntents[<>] /Metadata 264 0 R>> 2 0 obj A medical records release form is a document that allows you to share patient information with an outside party, such as an employer, an insurance company, a family member, another doctor or healthcare provider, or other third party. When people in Eastern Connecticut need help with behavioral health – whether for psychiatric illness or chemical dependency – they turn to Natchaug Hospital. Learn more about Medical Records at hartfordhealthcaremedicalgroup.org. One State Street, Suite 19, Hartford, CT 06103 • Contact Us. Authorization for Release of Health Information - English It is one of the largest teaching hospitals and tertiary care centers in New England. How can I obtain my medical records? 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. You'll need them if you change doctors, move, get sick when you're away from home, or end up in an emergency room. >>, Hartford HealthCare ha ampliado su capacidad de pruebas del COVID-19 y ubicaciones. Request Your Medical Records. One State Street, Suite 19, Hartford, CT 06103 • Contact Us Donations to Hartford HealthCare are managed by the Hartford Hospital Department of Philanthropy, a Connecticut tax-exempt organization under section 501(c)(3) of the IRS code (E.I.N. endobj endobj Windham Hospital. 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. For more information, click here. You can access your inpatient medical information online through our patient portal. For more information, click here. You must be 18 years of age or the parent or legal guardian of a minor patient or have some other legal authority to request a medical record. 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. 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. St. Vincent’s includes a licensed 473-bed community teaching hospital, a 76-bed inpatient psychiatric facility in Westport, a large multispecialty provider group, and St. Vincent’s Special Needs Services. You can request a copy of your health information by completing a Authorization to Release Information Form (Solicitud de Divulgación del Registro Médico del Paciente). 06-0646668). Form Revised: 1/2018 201177375_2 LAW AUTHORIZATION TO RELEASE INFORMATION LAST NAME MIDDLE NAME FIRST NAME ALL FORMER NAMES (Maiden, Alias, etc.) We are also committed to keeping your healthcare information private. The Hospital of Central Connecticut (THOCC) is a 414-bed, 32-bassinet, acute-care community teaching hospital with campuses in New Britain and Southington. Download and print the Authorization for Release of Health Information form below. Windham Hospital Medical Records (M - F 8:00 AM to 3:30 PM) 112 Mansfield Ave., Willimantic, CT 06226 Get Directions >> Phone: 860.456.6743 Fax: 860.456.6885 State-Of-The-Art comprehensive medical services, personalized attention and care an 867-bed Level 1 Center... Help with behavioral Health – whether for psychiatric illness or chemical dependency – they turn to Hospital! Phone • ( 860 ) 837-5785. fax to request a copy of your medical records the! Release copies of your medical records for your own personal use idea to keep copies your. Specialty HealthCare Release of records midstate medical Center is a 156-bed acute community. You would like a copy of your records, you can access your Health Information,... 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