Authorization to Release Behavioral Health Records

Authorization to Release Behavioral Health Records

This form authorizes Circle Care Center to release or obtain your protected health information (PHI) as described below.
Important: Behavioral health records are protected by HIPAA and Connecticut state law (CGS §§ 52-146d through 52-146q). These records require a separate, specific authorization and may not be released as part of a general medical records request.
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. Behavioral Health Records to be Released
From:*

MonthDayYear
To:*

MonthDayYear
All behavioral health recordsPsychotherapy notesProgress notes/treatment recordsPsychiatric evaluationMedication management recordsSubstance use treatment recordsOther
*If the records you are requesting include substance use disorder treatment records from a 42 CFR Part 2 program, those records are protected by additional federal restrictions and may not be re-disclosed by Circle Care Center without your separate written consent.
4. Purpose of Release
At the request of the patientContinued behavioral health careCoordinated medical 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.

• Connecticut law protections: Your behavioral health records are protected under CGS §§ 52-146d through 52-146q, which may provide broader privacy rights than HIPAA. Where state law provides greater protections, we will follow state law.

• 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 whether you provide this authorization, except in limited circumstances permitted by law.
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
For Circle Care Center staff use only:
Signature

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Date Records Released

MonthDayYear
Date
Should be Empty:

Authorization to Release Behavioral Health Records

1. Patient Information

2. Direction of Records

3. Behavioral Health Records to be Released

4. Purpose of Release

5. Your Rights & Expiration

Expiration of Authorization

6. Signature