Authorization to Release Medical Information

Authorization to Release Medical Information

This form authorizes Circle Care Center to release or obtain your protected health information (PHI) as described below.
Note: This form covers general medical records only. Behavioral health records (therapy notes, psychiatric evaluations, medication management, and substance use treatment) require a separate authorization. If needed, please click here to access our Behavioral Health Records Release form.
1. Patient Information
Name*

Legal First NameLegal Last Name
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Direction of Records
RELEASE -- send my records from Circle Care Center to the individual/institution belowOBTAIN -- request my records from the individual/institution below and send them to Circle Care Center
Institution or Individual*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Email
example@example.com
Norwalk (P: 203-852-9525 F: 203-854-0371)Glastonbury (P: 860-657-0764 F: 860-430-1736)
3. Records to be Released
From:*

MonthDayYear
To:*

MonthDayYear
All records (HIV and STI records require separate selection)Office progress notesBilling recordsImmunization recordsRadiology recordsEKG/EEG/EMG resultsHIV testing, status, diagnosis, or treatmentSTI testing, diagnosis, or treatmentOther
⚠ Sensitive Information Notice

If you selected HIV testing, status, diagnosis, or treatment or STI testing, diagnosis, or treatment above, you are specifically authorizing the release of that sensitive health information, which is protected under Connecticut law (CGS § 19a-583 et seq.). By signing this form, you confirm that release of any sensitive information you selected above is intentional and voluntary.
4. Purpose of Release
At the request of the patientContinued patient careInsuranceAttorney/ Legal requestDisability/ Social SecurityWorker's CompensationOther
5. Your Rights & Expiration
• Right to revoke: You may revoke this authorization in writing at any time, but revocation will not affect information that we have already used and disclosed. To revoke, contact our Privacy Officer at (203) 852-9525 x327.

• Re-disclosure: Protected health information that we disclose may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy laws or our Notice of Privacy Practices.

• Voluntary: Signing is voluntary. Your treatment will not be conditioned on signing this authorization.
Expiration of Authorization
Date

MonthDayYear
If left blank, this authorization will expire 1 year after signing this form.
6. Signature

By signing below, I confirm that I have read and understand this authorization.
Patient Signature

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Name

First NameLast Name
Today's Date

MonthDayYear
Date
If signed by a representative:
Representative Signature

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Name

First NameLast Name
Today's Date

MonthDayYear
Date
Relationship to Patient
Witness or Interpreter
Should be Empty:

Authorization to Release Medical Information

1. Patient Information

2. Direction of Records

3. Records to be Released

4. Purpose of Release

5. Your Rights & Expiration

Expiration of Authorization

6. Signature