Authorization Release Form

Patient Information

Patient Name(Required)
MM slash DD slash YYYY
Address(Required)
I hereby authorize Shared Response Health Systems, LLC to release/disclose information to:
Address(Required)

Purpose Of Disclosure

At Patients Request
Legal
Other

Information To Be Released As Follows

Inspection Only
All medical records, including reports and bills
Medical or billing information as specified:
  1. I understand that this authorization will expire one year after I have signed this form, or other time frame as specified below
  2. I understand that I may revoke this authorization at any time by notifying Shared Response Health Systems, LLC in writing, and such revocation will be effective on the date Shared Response Health Systems, LLC receives written notice except to the extent that action has already been taken in reliance upon this authorization.
  3. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy regulations.
  4. I understand that I am not required to sign this form in order to receive treatment.
  5. I understand that there may be a fee for a copy of my medical record.
  6. I understand that information to be released may include mental health information in accordance with C.G.S. § 52- 146d, substance abuse information in accordance with 42 CFR 2, and/or HIV/AIDS-related information in accordance with C.G.S. § 19a-581 et seq., except as indicated:
Except as indicated

Signature Fields

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MM slash DD slash YYYY
Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY
A copy of the patient's and/or signee 's government-issued identification must accompany this request. If applicable, proof of appointment of Power of Attorney or Conservator must be submitted.

NOTE TO RECIPIENT OF INFORMATION:
Confidentiality of psychiatric, drug and/or alcohol abuse, and HIV/AIDS related records is required and no information from these specific records shall be transmitted to anyone else without written consent or authorization as provided under Connecticut General Statutes Chapters 899 and 368x and Federal Regulations 42 CFR 2. These laws prohibit you from making any further disclosure without specific written consent of the person to whom it pertains. A general authorization for the release of information is NOT sufficient for this purpose.
Legal Consent(Required)