Health Services - Authorization for Access/Release of Information

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Patient Name: Patient Name: First Middle Last
Date of Birth: Date of Birth: / MM / DD YYYY
Cell Phone: Cell Phone: - ### - ### ####
Email:
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Dates Attended the University (Start Date - End Date):
This information is to be used for the purpose of:

This information is to be used for the purpose of: Self Further Medical Care Mental Health Resources School Work Attorney Insurance Eligibility/Benefits Disability Other Other
I hereby authorize the University of New Haven to:

I hereby authorize the University of New Haven to: Release information from my medical record to: Obtain information from:
Name of Facility or Institution:
Attention (Name of Person): Attention (Name of Person): First Last
Phone: Phone: - ### - ### ####
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Method of Disclosure:

Method of Disclosure: Mail (to address listed above) Pick-Up (Photo ID Required) Fax: Fax:
Pick-Up By (Photo ID Required):
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Please indicate records you are requesting by checking boxes below:

Please indicate records you are requesting by checking boxes below: University of New Haven Yale-New Haven Hospital Northeast Medical Group Other Other
Release Content:

Release Content: History & Physical Discharge Summary Emergency Visit Procedure Report Stress Test ED Record Progress Notes EKG Laboratory Results X-Ray CD X-Ray Report Pathology Report Insurance Information Echocardiogram Immunizations Other Other
Date(s) of Service Requested:

Enter date range of service requested here.
For questions contact the University of New Haven Health Services at 203-932-7079.

Fax: 203-931-6090

Health Services - Authorization for Access/Release of Information

Health Services - Authorization for Access/Release of Information

For questions contact the University of New Haven Health Services at 203-932-7079.