4 0 obj (85 Seymour Street, Suite 505, Hartford, CT 06106-5524) ... authorization for the release of medical or other information is NOT sufficient for this purpose. 10 Columbus Blvd, Hartford, CT 06106 • (860) 837-5780. phone • (860) 837-5785. fax . 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 Offices. %PDF-1.4 More COVID-19 testing locations and expanded hours. It's a good idea to keep copies of your medical records. (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.) 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. 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 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. <> 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. Mail the completed form to: Gaylord Specialty Healthcare Release of Information P.O. Learn more about Detail at hhcintweb02-web.hartfordhealthcare.org 06-0646668). For more information, click here. For more information, click here. 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. 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). Request medical records from Froedtert Hospital (Milwaukee, Wis.), ... Hartford, WI 53027 Ph: 262-836-2510 Fax: 262-836-8490. WWW.CONNECTICUTCHILDRENS.ORG . Mail or fax the completed form using the information listed below. Form Revised: 1/2018 201177375_2 LAW AUTHORIZATION TO RELEASE INFORMATION LAST NAME MIDDLE NAME FIRST NAME ALL FORMER NAMES (Maiden, Alias, etc.) Or, you can fax the form to 262-928-5756. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/StructParents 0>> Learn more about when and where you can be vaccinated. 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. Authorization for Release of Information to a third-Party (a Non-UCLA Provider, Insurance Company, Attorney, etc.). Box 400 Wallingford, CT 06492. 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 If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form. 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. The Medical Records form is available online ( below ) or can be obtained by visiting the Health Information Management Department during normal business hours. We can provide or release copies of medical records at the written request of patients or their authorized legal representatives. endobj 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. Hartford HealthCare Medical Group medical records and release of information. 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. 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 >> Download and print the Authorization for Release of Health Information form below. HH Forms 575064 R12-18 Printed by the Digital Print Center @ HH ... notifying Hartford Healthcare Medical Group. This form template authorizes your healthcare provider to release your private medical records to the parties you specify. >>, How to obtain a copy of your Medical Records from. Authorization Form to Obtain/Disclose Health Information. There may be a per-page fee for copies. The Hospital of Central Connecticut (THOCC) is a 414-bed, 32-bassinet, acute-care community teaching hospital with campuses in New Britain and Southington. <>/OutputIntents[<>] /Metadata 264 0 R>> Sub­mit your com­plet­ed paper autho­riza­tion form to Record Con­nect by email­ing a copy to dupage. 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. 06-0646668). >>, The vaccine is here! If you request copies of your medical records, you’ll pay: 12 cents per page for up to 100 pages 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. Fees. To request a copy of your medical record, please print out and complete the form below. 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. Get the latest healthcare news directly in your inbox. One State Street, Suite 19, Hartford, CT 06103  •  Contact Us. Medical Records Request. ��>�+�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�. Learn more about Medical Records at hartfordhealthcaremedicalgroup.org. 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). Medical Records Request . AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION You may submit the form by mail, in person, or by email to: release_of_information@midhosp.org . 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. status@ recordconnectinc. Your medical records can be sent to anyone, including health care providers, employers or organizations. 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. [|���K��b�����1�##>�ׇd���>W�_��u7�[��|� 06-0646668). We are inviting entrepreneurs from across the world to evaluate proposed new technologies and products with our clinical experts. 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. Authorization for Release of Health Information - English A not-for-profit Medicare insurance company formed by Hartford HealthCare and Tufts Health Plan. Windham Hospital. 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. 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. Request Your Medical Records. You can access your inpatient medical information online through our patient portal. 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 have questions, please call 262-696-5844. We are also committed to keeping your healthcare information private. 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