Medical Records Autorization Form

NOTE: 

• Phone requests for information will not be accepted.
• Radiology images (films) are not part of your medical record. (i.e., your records contain reports of interpretations of such images). Contact the Radiology Department to obtain films. (203) 576-5070
• Your medical record does not contain your Billing Statements.
• The Financial & Insurance Information section of this website contains instructions on how to obtain billing data.

Click in to download the pdf and follow these directions:

1. Complete an Authorization for Disclosure of Protected Health Information (PDF) to disclose records to anyone, including the patient. A handwritten note from the patient will not suffice for authorization to disclose records.
2. Please Print
3. Indicate dates of treatment, especially if you've had multiple episodes of care.
4. Indicate what type of records you need.
5. If you aren't sure what information you need, please give us a call at (203) 576-5193.