Medical Records Release

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Authorization to Release Health Information

Patient Name:

Date of Birth:

Phone

Other Names Patient has Used:

Send Records to:

I authorize this information to be faxed.

do
do not

If yes, fax number: (203) 661-2597

This information is being disclosed for the purpose of Continuing Health Care.

I understand that specific information to be released may include AIDS or HIV, Alcohol and/or Drug Abuse, and Mental Health.

The physician and employees are released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. I understand that this authorization may be evoked in writing at any time, except to the extent that action has been taken in reliance on this authorization for the purposes stated above.

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