Medical Records Release/Request Form (Please complete all blanks)
We suggest that you keep a set of your medical record you requested. We shall send your medical record to you UNLESS you want us to send it to your doctor, _________________________________________________
by mail or by fax (please state clearly the doctor’s address, phone number and/or fax number).
Please Send to (who) _________________________________ Address ______________________________________________
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Patient Authorization for Use or Disclosure of Protected Health Information
As required by the Health Portability and Accountability Act of 1996 (HIPAA) and Connecticut Law, this practice may not use or disclose your identifiable health information without your authorization except as provided in our Notice of Privacy Practices. Your completion of this form means that you are giving permission for the uses and disclosure described below. Please review and complete this form carefully. It may be invalid if not fully completed. You may wish to ask the person or entity you want to receive your information to complete the sections detailing the information to be released and the purposes for the disclosure.
I hereby authorize Obstetrics & Gynecology Associates, Whittingham Pavilion, Suite G401, 190 W.Broad Street,
Stamford, CT 06902-3633 to release health information of patient named below:
Patient Name: (Print please) ____________________________________________ Date of Birth: _______________________
(Other names, Maiden name): ____________________________________ Last 4-digit of Social Security Number:___________
Address ___________________________________City ____________ State ______ Zip __________ Phone _______________
Dates of Service to Release: ________________________________________ OR ______ the entire Medical Record
Reason for release (must be noted on this form) _______________________________________________________________
Restrictions: I understand that the recipient of this information may not use or disclose this information except for the expressed purposes identified above, unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law.
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), OR HUMAN IMMUNODEFICIENCY VIRUS (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
Exclusion (please initial): Drug/Alcohol _______, Mental Health/Psychiatric _______, Sexually Transmitted Disease _______,
HIV/AIDS _______, other _______, Description of other exclusion: _______________________________________
This authorization is effective this date: _________________ through _________________(dates must be specified).
Signature: r___________________________Print Name: ______________________________ Date:____________________
If this form is completed by someone other than the patient, please print name and address below and check the appropriate box. Name: __________________________________________________________________________________________
Address:________________________________________________________________________________________
I am the __ Guardian __ Conservator __ Other (please specify): ______________________________________
I understand that I have the right to receive a copy of this authorization.
Refusal to Sign Authorization
I understand that my health care treatment or benefits will not be affected whether I sign or do not sign this form.
I understand that I may revoke this authorization at any time by notifying this medical practice in writing as described in the Notice of Privacy Practices. My revocation will not affect actions taken by this medical practice prior to its receipt.
I understand that, if the recipient of the information is not a health care provider or health plan covered by HIPPA. The information used or disclosed as described above may be redisclosed by the recipient and no longer protected by HIPPA. However, other state of federal law may prohibit the recipient from disclosing specially protected information, such as abuse treatment information,
HIV/AIDS -related information, and psychiatric/mental health information. HIPPA Compliant Patient Authorization Rev.10/17/08 lpc
The Connecticut general statutes allows for the charge of 65 cents per page as referenced by section 27c(b).
The office of Obstetrics & Gynecology Associates will copy your medical record at 50 cents per page plus shipping and handling, if any, minimum $5.00 per request. Fees are payable in advance, we accept MasterCard, VISA and DISCOVER.
Please circle one: MasterCard VISA Name on Card __________________________________
Account Number: _______________________________________________ Expiration ______/______
Amount $ _____________ Signature: ____________________________________________________
Obstetrics & Gynecology Associates, Whittingham Pavilion, Suite G401, 190 W.Broad Street, Stamford, CT 06902-3633
