This form template authorizes your healthcare provider to release your private medical records to the parties you specify. The Medical Records form is available online ( below ) or can be obtained by visiting the Health Information Management Department during normal business hours. >>, The vaccine is here! 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 >> Learn more about Medical Records at hartfordhealthcaremedicalgroup.org. Request for Medical Records. How can I obtain my medical records? Request Your Medical Records. 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. AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION The Froedtert & the Medical College of Wisconsin regional health network is a partnership between Froedtert Health and the Medical College of Wisconsin. Contact the Medical Records Department. 1. (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.) 06-0646668). Records Dept. You may submit the form by mail, in person, or by email to: release_of_information@midhosp.org . Mail or fax the completed form using the information listed below. Fees. endobj Authorization for Release of Health Information - English Request medical records from Froedtert Hospital (Milwaukee, Wis.), ... Hartford, WI 53027 Ph: 262-836-2510 Fax: 262-836-8490. Authorization for Release of Information to a third-Party (a Non-UCLA Provider, Insurance Company, Attorney, etc.). It's a good idea to keep copies of your medical records. We can provide or release copies of medical records at the written request of patients or their authorized legal representatives. 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. 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). Learn more about Detail at hhcintweb02-web.hartfordhealthcare.org %���� <>/OutputIntents[<>] /Metadata 264 0 R>> MidState Medical Center is a 156-bed acute care hospital located in Meriden, Connecticut, with satellite offices in Cheshire, Wallingford and Southington. To obtain a copy of a medical record from The MetroHealth System, download, complete, sign, and date the Authorization to Release Protected Health Information (or Autorización para Divulgar Información de Salud) and mail to the attention of the Health Information Services Department according to the address provided on the form. 06-0646668). Windham Hospital. You'll need them if you change doctors, move, get sick when you're away from home, or end up in an emergency room. (85 Seymour Street, Suite 505, Hartford, CT 06106-5524) ... authorization for the release of medical or other information is NOT sufficient for this purpose. 06-0646668). 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 stream To request copies of your medical records, print and complete the Authorization for Use and Disclosure of Protected Health Information form below. 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. 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. 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). You may request a copy of your medical records at any time, but all requests must be in writing. Your medical records can be sent to anyone, including health care providers, employers or organizations. Authorization Form to Obtain/Disclose Health Information. 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. Requests for records should be made by using the Authorization for Release of Information forms below. One State Street, Suite 19, Hartford, CT 06103  •  Contact Us. 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. endobj If you request copies of your medical records, you’ll pay: 12 cents per page for up to 100 pages HH Forms 575064 R12-18 Printed by the Digital Print Center @ HH ... notifying Hartford Healthcare Medical Group. 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. To request a copy of your medical record, please print out and complete the form below. Or, you can fax the form to 262-928-5756. 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 you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form. Medical Records Request. Hartford Hospital can provide or release copies of medical records at the written request of patients or their authorized legal representatives. Mail or drop off the form at: Health Information Management – Release of Information N17 W24100 Riverwood Dr., Suite 200 Waukesha, WI 53188. 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