Connecticut Release of Information Form
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Patient Full Name: __________________________________ Previous Names (if applicable) _____________________
Patient Address: _______________________________________________ Date of Birth: ________________________
City: ______________________

State: ________ Zip Code: ___________ Phone #: ___________________________

I authorize any member of the medical staff of Connecticut Children’s Medical Center and/or Connecticut Children’s
Specialty Group or any of its employees or representatives to use and/or disclose my protected health information (PHI)
as provided below. I understand that I may revoke this Authorization, except to the extent that the entity has already taken
action in reliance on this Authorization. The written revocation letter needs to be sent to the Health Information
Management (HIM) Department of Connecticut Children’s Medical Center. The provision of treatment will not be
conditioned on the completion of this Authorization. I understand that once