Backus r, Hospital A Hartford HealthCare Partner

The William W. Backus Hospital 326 Washington Street Norwich CT 06360

Phone: 860-823-6382 Fax: 860-892-2723

AUTHORIZATION TO DISCLOSE/OBTAIN HEALTH INFORMATION

Subject to the statements printed on the back, I, the undersigned patient or legal representative, hereby authorize the use and disclosure of health information including, if applicable, information relating to the diagnosis or treatment of mental illness, drug and/or alcohol abuse and HIV related information.

Patient Name:

Date of Birth:

IH ROID

AKA (Other Names) MRN

FILL OUT FOR BACKUS HOSPITAL TO DISCLOSE FILL OUT FOR BACKUS HOSPITAL TO OBTAIN

I authorize the Backus Hospital to disclose health information to:

Name:

I authorize

To disclose health information to Dept:

Facility:

Backus Hospital 326 Washington Street Norwich CT 06360

Contact Person:

Address:

Tele#:

Fax#: Tele#:

Fax: Method of Disclosure:

0 Mail 0 Fax 0 Pick-up 0 Email(Secured) 0 Verbal 0 Review

The dates of service and the type(s) of information to be used or disclosed are as follows:

Date(s) of Treatment:

0 History & Physical 0 Discharge Summary 0 ED Record 0 Operative Reports 0 Consultations

0 Laboratory/Path 0 Radiology Reports 0 Radiology Films 0 Progress Reports 0 Billing Records

CI Mental Health 0Substance Abuse 0 HIV Test Results / Immunodeficiency Virus

0 Entire Record 0 Other

The purpose of this disclosure or use is for the following reason:

0 Medical 0 Legal 0 Disability CI Insurance 0 At the request of the patient 0 Other

• This authorization will be valid for a period of one year from the date below. • I understand that I may revoke this authorization at any time by notifying the Health Information Management Department in

writing. I understand that the revocation will not apply to information that has already been released in response to this authorization.

• I understand that under applicable law the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal privacy regulations

• I understand that my treatment or continued treatment by Backus Hospital is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it.

• I understand there may be a charge for copies of my medical record of $.65 per page/$15 per Radiology CD per State Law. • The parent or legal guardian must sign this authorization if the patient is a minor (under age 18) or has a legal

Guardianship except in the case of an emancipated minor, minors receiving drug abuse treatment, minors receiving treatment of venereal disease or pregnancy over the age of 12.

Signature of Patient or Legal Representative

Date Time

Witness Signature (if applicable)

Date Time

Relationship to patient: 0 Self ❑ Parent 0 Guardian 0 Conservator CI Executor of Estate 0 Power of Attorney

0 Other If signed by the legal Representative attach appropriate documentation to verify authority

Rev 3/05, 10/14 Page 1 of 2

Backus `.45 Hospital

001

A Hartford HealthCare Partner The William W. Backus Hospital

326 Washington Street Norwich CT 06360 Phone: 860-823-6382

Fax: 860-892-2723

ROID

HIV RELATED INFORMATION In the event that information release constitutes confidential HIV related information protected under Connecticut Law: this Information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

PSYCHIATRIC INFORMATION If the event that information released constitutes confidential psychiatric information protected under Connecticut Law: This information has been disclosed to you from records whose confidentiality is protected by state law. State law Prohibits you from making any further disclosure of it or of using it for any purpose other than that indicated above without The specific written consent by the person to whom it pertains, or as otherwise permitted by said law.

DRUG AND ALCOHOL ABUSE RECORDS In the event that information released is protected by the HHS Confidentiality of Alcohol and Drug Abuse Patient Records Regulations:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly Permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general Authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict Any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Rev 3/05, 10/14 Page 2 of 2

IVYALE NEW HAVEN HEALTH

Phone: 203-688-2231 Fax: 203-688-4645

Authorization to Release/Disclose Protected Health Information

Patient Name:

(Last)

(First)

(Middle Initial) (Maiden/Other Name)

Date of Birth: Phone: Fax:

Complete Address (street or box#, city, state, zip)

This information is to be used for purpose of: ❑ Self ❑ Further medical care ❑ Attorney ❑ Changing Physicians ❑ Disability ❑ Workers Comp ❑ Insurance Eligibility/Benefits ❑ Other

I hereby authorize Yale-New Haven Health entity(ies) named below to release information from my medical record to:

Name: Phone/Fax:

Address:

Method of Disclosure:

❑ Mail ❑ Pick Up (Photo ID Required)

City/State: Zip Code:

(Date Time To be Determined by Office Staff)

1:Fax (Physician or Health Care Providers Only - all information is to be completed

(Name of Physician or Facility)

(Street Address)

(City/State)

(Zip)

(Phone #) (Fax # )

Please indicate records you are requesting by checking boxes below:

❑ Yale-New Haven Hospital ❑ Hospital of Saint Raphael prior to 09/12/2012 ❑ Bridgeport Hospital ❑ Greenwich Hospital 1:Northeast Medical Group ❑ Smilow Care Center ❑ Cardiology ❑ Urology

Release Content: Date(s) of service requested: From: To:

❑ History & Physical ❑ Path Report ❑ Lab Results ❑ Stress Test

❑ Discharge Summary ❑ ED Record ❑ X-ray CD ❑ Laboratory Results

❑ Emergency Visit ❑ Progress Notes DX-Ray Report ❑ Billing Record

❑ Procedure/Operative Report ❑ PT/OT/Speech Notes ❑ Pathology Report ❑ Echocardiogram

❑ Immunization ❑ Cancer Center ❑ EKG ❑ Other

For Internal Use Only: MRN: CSN:

II 10 F4918

1 111 I 1 II F4918Eng (Rev. 01/14)

***HIV-BEHAVIORAL HEALTH- DRUG/ALCOHOL INFORMATION contained within the medical records indicated above will be released through this authorization unless otherwise indicated below. (Any records containing any of this information requires signature from age 13 and older to sign for release of records)***

Indicate which you do NOT want released with your initials:

HIV Substance Abuse which includes Alcohol & Drug Abuse Pregnancy Test Genetic Testing

Behavioral Health/Psychiatric Sexually Transmitted Disease Other (please list)

• The authorization is valid for one year from the date below. I understand that after I have signed this form, I may change my mind and cancel (revoke) this authorization at any time by contacting in writing the YNHHS Medical Information Unit. Cancellation of the authorization will not apply to information that has already been released based on this authorization.

• I understand the information disclosed in response to this authorization may be subject to re-disclosure by recipient, and will no longer be protected under the terms of this authorization of by federal privacy regulations.

• I understand that this authorization is voluntary and my treatment by YNHSS is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. If I do not sign this form, payment for this care will only be affected if my health care insurer is requesting this information and is permitted to require this authorization.

• I understand that I may see and copy the information described on this form if I ask for it. There is a charge for copies in accordance with Connecticut law.

• The parent or legal guardian must sign this authorization if the patient is a minor (under age 18).

Authorization can be sent to:

Medical Information Unit PO Box 9565 New Haven, CT 06535

Printed Name: Date: Time:

Signature of Patient or Authorized Representative **must provide proof of authority (except parent of a minor)

Please check relationship to patient and if other than patient, reason patient cannot sign

❑ Self ❑ Parent ❑ Legal Guardian ❑ Executor/Administrator of Estate ❑ Healthcare Representative ❑ Conservator ❑ Other Authorized Legal Representative (indicate) Reason - ❑ Incompetent ❑ Disabled

AUTHORIZATION FOR PERSONAL REVIEW OF MEDICAL RECORD I request that I be permitted to review my medical record. I understand that any amendments can be requested by doing so on the Patient Amendment Form.

Printed Name: Date: Time:

Patient's Signature: Phone (required)

You will be notified by phone for appointment time to view

lures The Charlotte Hungerford Hasprtal

THE CHARLOTTE HUNGERFORD HOSPITAL HIPAA AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION

Patient/Client Name: Medical Record #:

Date of Birth: Telephone No. Address:

, authorize ❑ The Charlotte Hungerford Hospital ❑ The Charlotte Hungerford Hospital On behalf of Torrington Radiologists, PC / AMI

to release my medical records, including a copy of my entire mental health record, including psychiatric and drug information, and information regarding my AIDS/HIV status, treatment or testing, emergency room records, nursing notes, laboratory results, pathology reports, x-ray reports, films, all consent forms, and a copy of the bill for services rendered, to (who):

I authorize the disclosure of the following information: (what)

The information will be used / disclosed for the following purposes (why— i.e. continuing care, personal, legal):

If any of the information to be released constitutes a psychiatric communication or a communication with a psychologist, or any other mental health worker, this release will serve as my written release of that information. I understand that my refusal to grant consent for this release of mental health information will in no way jeopardize my right to continue to obtain treatment, except where disclosure is necessary for treatment or permitted by law. I understand that no psychotherapy notes may be disclosed by my signing this authorization, and that a separate authorization would be required for the release of psychotherapy notes.

If any of the information to be released relates to treatment for alcohol or drug abuse, I understand that such information is subject to the requirements of Part 2 of Title 42 of the Code of Federal Regulations which prohibits the further release of such information without my consent, as referenced in the federal regulations, or as otherwise permitted by law.

This authorization will expire in 6 months, and may be revoked by me, at any time, in writing, except to the extent that action has been taken in reliance thereon. This authorization is valid unless and until it is revoked and properly presented to our records office. [Authorization must be currently dated within the past 6 months and dated after the information you are requesting, per Hospital Policy.]

I understand that if the person or entity that receives the information is not a health care provider or health care plan covered by the federal privacy regulations, the information described above may be redisclosed and no longer protected by those regulations.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or copy any information used/disclosed under this authorization.

Signature of Patient: Date: Or Signature of Parent, Guardian or Legal Representative Specify Relationship:

(Section below is to be filled out upon receipt of requested medical records.)

I have reviewed and/or received photocopies of the medical records listed above:

Signature of Patient/Client Date

Relationship to Patient if signed by someone other than the Patient/Client Health Information Management FAX: 860-496-6629 PHONE: 860-496-6672 304 061 R 05/08 I

* Recipient of Materials See Reverse Side of Form

1 11111111 11111 1111 III IIII

TO THE RECIPIENT OF THESE MATERIALS:

If the information disclosed constitutes confidential HIV/AIDS information, it is protected under Connecticut law as follows:

"This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law. A general authorization for the release of medical or other information is NOT sufficient for this purpose."

Any oral disclosure shall be accompanied or followed by the above notice within 10 days. See Connecticut General Statutes section 19a-585.

PSYCHIATRIC COMMUNICATIONS: If the released material contains confidential psychiatric communications, as designated in C.G.S. sections 52-146d through 52-146i, inclusive, please note the following:

"The confidentiality of this record is required under Chapter 899 of the Connecticut general statutes. This material shall not be transmitted to anyone without written consent or other authorization as provided in the aforementioned statutes."

A copy of the consent form setting forth any limitations shall accompany the disclosure.

DRUG & ALCOHOL TREATMENT: No person, hospital, treatment facility or department of health may disclose or permit the disclosure of the identity, diagnosis, prognosis or treatment of any patient in a treatment for drug and\or alcohol abuse that would be in violation of federal or state law. In the event that the records contain information regarding drug and\or alcohol abuse treatment, please note the following legal requirements and prohibitions:

"This information has been disclosed to you from records protected by federal and state confidentiality rules (2 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient."

See Connecticut General Statute section 17a-688.

ADDRESS: E-MAIL ADDRESS:

PATIENT'S NAME: DATE OF BIRTH:

STATE: ZIP CODE TO#: CITY: PHONE NUMBER:

UCONN HEALTH

(Patient Identification)

Authorization to Obtain and/or Disclose Health Information

1. I hereby authorize UConn Health to disclose and/or obtain my individually identifiable health information as described here to the person/organization named below. I understand that this authorization is voluntary and that it may include information relating to AIDS, HIV infection, behavioral health services/psychiatric care, treatment for alcohol and/or drug abuse.

2. Dates of Service

3. Information: ❑ to be disclosed or ❑ to be obtained (PLEASE CHECK INFORMATION NEEDED BELOW) ❑ Discharge Summary ❑ Radiology films ❑ History & physical examination ❑ Radiology reports ❑ Consultation reports ❑ Inpatient record, including Psychiatric Inpatient ❑ Emergency Dept. record ❑ Laboratory tests ❑ Rehabilitation Dept. notes ❑ Outpatient clinic notes- List clinic here: ❑ Outpatient Behavioral Health notes ❑ University Dentists notes/Dental Clinic notes ❑ Entire record (ONLY when subsections of the record will not serve the intended purpose of the disclosure.) ❑ Other (please specify):

4. Please DO NOT release the following information:

5. I am requesting that this information be disclosed obtained ❑ for the purpose of (i.e. Legal reasons, continued care, insurance, another medical opinion, Worker's compensation, research, personal use, Social Security):

6. Name of the person(s)/organization(s): To whom the disclosure is to be made ❑ or From whom the information is to be obtained ❑

For release to PATIENTS only specify: ❑ Paper Copies ❑ Electronic format (for electronically kept records only) List preferred electronic format:

Paper copies will be provided unless otherwise specified

If the disclosure is made to or obtained from more than one person/organization for the same purpose, more than one entry may be made below.

NAME PHONE NUMBER

ADDRESS

CITY STATE ZIP

NAME PHONE NUMBER

ADDRESS

CITY STATE ZIP

7. If authorization is to obtain information, please provide information to: UConn Health Provider Name: Department: Mail Code: Phone Number: Fax: Address: Zip code:

8. Name and relationship to patient of individual authorized to pick up record(s) being released from the facility:

*HCH551* HCH-551 Eff. 7/2003 Rev. 7/04, 9/06, 8/11,1/12, 9/13, 1/16 Page 1 of 2 DS

UCONN HEALTH

(Patient Identification)

Authorization to Obtain and/or Disclose Health Information

9. This authorization may be revoked in writing to the Director of Health Information Management at any time, except to the extent that action has already been taken in reliance on this authorization. This authorization shall automatically expire 6 months from the date of signature unless otherwise specified in the space provided here.

DATE OF EXPIRATION:

10. I may inspect and copy the information to be used and disclosed under this authorization and that I may receive a copy of this signed authorization form. There may be a fee associated with producing the records, not to exceed what Connecticut State law authorizes.

11. UConn Health, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

12. UConn Health may not condition treatment on the provision of this authorization except in cases of research-related treatment protocols or studies being conducted by outside third parties through UConn Health. In such cases, specific authorization for the research-related treatment protocols/studies must be signed as a condition of participation. In cases where UConn Health is requested by a third party to create health information solely for the purpose of sharing that information with the party that requested it, I understand that I must sign this authorization.

13. Notice to Recipients: As the recipient of this information, you may use this information only for the stated purpose. You may disclose this information to another party ONLY:

■ With written authorization from the patient or his or her legal representative; ■ As required or authorized by state and / or federal law; or ■ If urgently needed for the patient's continued care.

If this disclosure contains information relating to HIV, behavioral health, alcohol or drug abuse education, training, treatment, rehabilitation, or research, the following shall apply: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (Title 42 CFR Part 2) and Connecticut General Statutes (Ch. 368x) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

14. Notice to Individual Requesting the Disclosure: Your signature below indicates that you understand that if the organization authorized to receive the information is not a health care provider or health plan, and the information disclosed is NOT protected by Title 42 CFR Part 2 and Ch. 368x, then the released information may no longer be protected by the HIPAA Federal Privacy Regulations.

Printed Name of Patient

Signature of Patient or Legal Representative

Date/Time

Printed name of Legal Representative * Relationship to Patient *A copy of the personal representative's legal authority to act on behalf of the patient is attached.

Signature of Individual Picking up Record

For Office Use Onl

Relationship to Patient

Sign & Date Check identification Date records needed by: Charges: Copy of Authorization was provided to patient

NOTES: **(When using this form in the Laboratory, a physician signature is required to disclose results to anyone.)

Physician Signature

Date/Time

PLEASE MAIL COMPLETED FORM TO: RELEASE OF INFORMATION, HEALTH INFORMATION MANAGEMENT DEPARTMENT MAIL CODE 2260, 263 FARMINGTON AVE, FARMINGTON, CT 06030

Questions? Please call 860-679-2787. For East Hartford and West Hartford related requests call 860-523-3774.

HCH-551 Eff. 7/2003 Rev. 7/04, 9/06, 8/11,1/12, 9/13, 1/16 Page 2 of 2 DS

New Britain General Campus Attn: Health Information Mgmt 100 Grand Street New Britain, CT 06050 Fax: 860-224-5920

The Hospital ‘' ♦ of Central Connecticut A Hartford HealthCare Partner

Bradley Memorial Campus Attn: Health Information Mgmt 81 Meriden Avenue Southington, CT 06489 Fax: 860-276-5081

AUTHORIZATION FOR RELEASE OF INFORMATION

I, the undersigned patient or legal representative, hereby authorize The Hospital of Central Connecticut to disclose or obtain health information, including if applicable, information relating to the diagnosis or treatment of mental illness, drug and/or alcohol abuse and confidential HIV related information regarding:

Patient Name: Birthdate: / / Phone:

Information may be 0 Disclosed to 0 Obtained from Other Facility

3. The dates of service and the type(s) of information to be used or disclosed is as follows:

Date(s) of Service:

Name/Facility:

Mailing Address: 0 Inpatient COutpatient 0Emergency Visit

4. Requested Information:

OComplete Record ElAbstract Only

Please specify if you need specific reports only:

City/State/Zip

Phone #: -

( ) OHistory & Physical OLaboratory Report ODischarge Summary OX-Ray Report COperative Reports OEKG Report OConsultations DX-Ray Films (Radiology Dept) Milling Statement (Patient Accounts Dept) OOther (please specify)

[ ] Hand-Carry [ ] Fax to:

2. The purpose of this disclosure or use is for the following reason: 0 Medical 0 Legal 0 Disability 0 Insurance

0 At the request of the patient or legal representative

0 Other (please specify)

I understand that my treatment or continued treatment by The Hospital of Central Connecticut is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. I understand that under applicable law the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal privacy regulations. I understand that I may inspect or request a copy of the information to be used or disclosed by the recipient.

This authorization will be valid for a period of one year from the signature date below. Medical records will only be released for dates of service which occur prior to the authorization date unless disclosure of a future service date is specifically authorized. I understand that I may cancel this authorization at any time by notifying the Health Information Management Department in writing, but if I do it will not have any effect on actions that the hospital took before it received the cancellation.

Copy Fees: I understand that The Hospital of Central Connecticut may charge a fee for copying and first class postage to the individual receiving the requested information. Copy fees will be applied in accordance with Connecticut Statute at $0.65 cents per page.

Signature of Patient or Legal Representative Date

Printed Name

If not patient, state the relationship to patient below (legal documentation required as applicable): OParent EIGuardian ElConservator DExecutor of Estate 0 Power of Attorney ElOther:

NOTE: The confidentiality of psychiatric, alcohol, drug and HIV related records is required by Connecticut General Statutes and/or Federal Regulations 42 CFR, part 2. This information shall not be re-disclosed to anyone else without written consent or other authorization as provided in the Connecticut General Statutes and/or Federal Regulation 42 CFR, part 2. A general authorization for the release of medical information is not sufficient for this purpose.

NBGH Form #1001, rev 3/17/11

AUTHORIZATION FOR RELEASE OF INFORMATION

VITRI3t IOSPITA .

Electronic Record Delivery Request

Patient Name:

DOB.

Address:

Email Address.

Must be completed along with HIPAA Authorization

CN3300A Rev. 11/5/2014 Page 3 of 3

1111111111111

11111111111111111113131101A111111111111

WATERBURY HOSPITAL \V VI l'12131 'RV

Waterbury, Connecticut

Authorization to Disclose Health Information

1. I hereby authorize The Waterbury Hospital to disclose my individually identifiable health information as described here to the person/organization named below. I understand that this authorization is voluntary and that it may include information relating to AIDS, HIV infection, behavioral health services / psychiatric care, treatment for alcohol and/or drug abuse.

PATIENT'S NAME DATE OF BIRTH

ADDRESS SOCIAL SECURITY NUMBER (last 4 digits only)

XXX — XX —

CITY STATE ZIP CODE PHONE NUMBER

Dates of Service:

2. Information to be disclosed:

O Discharge Summary

0 Radiology films/CD

1E1 History & Physical examination

0 Radiology reports

El Consultation reports

0 Psych/Drug/Alcohol/HIV

El Emergency Room record

El Laboratory tests

El Entire record (Consideration will be given to releasing the entire record ONLY when subsections of the record will not serve the intended purpose of the disclosure.)

❑ Other (please specify):

El Bills

3. I understand that information to be released or obtained may include mental health information in accordance with CGS 52-146(d), substance abuse treatment information in accordance with 42 CFR 2.12.67, and/or HIV/AIDS - related information in accordance with CGS 19a-586(a), except as indicated below.

El No Mental Health

El No Substance Abuse treatment information 11 No HIV/AIDS

4. Name of person(s) / organization(s) to whom the disclosure is to be made:

NAME

TELEPHONE NUMBER

ADDRESS

CITY

STATE ZIP CODE

or name and relationship to patient of the individual authorized to pick up the record(s) being released from the facility:

5. I am requesting that this information be disclosed for the purpose of (i.e., Legal reasons, continued care, insurance, another medical opinion, Worker's compensation, research, personal use, Social Security):

6. I understand this authorization may be revoked in writing at any time, except to the extent that action has already been taken in reliance on this authorization. This authorization shall automatically expire 6 months from the date of signature unless otherwise specified in the space provided here. DATE OF EXPIRATION:

CN3300A Rev. 11/5/2014

Page 1 of 3

7. I understand that I may inspect and copy the information to be used and disclosed under this authorization and that I may receive a copy of this signed authorization form. There may be a fee associated with copying, not to exceed what is authorized by Connecticut State law.

8. The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

9. I understand that Waterbury Hospital may not condition treatment on the provision of this authorization except in cases of research-related treatment protocols or studies being conducted by outside third parties through Waterbury Hospital. In such cases, specific authorization for the research-related treatment protocols / studies must be signed as a condition of participation.

10. I understand that my personal health information will be released in a paper format unless otherwise specified.

❑ Electronic Copy

Notice to Recipients:

As the recipient of this information, you may use this information only for the stated purposes. You may disclose this information to another party ONLY:

■ With written authorization from the patient or his or her legal representative; ■ As required or authorized by state and / or federal law; or ■ If urgently needed for the patient's continued care.

If this disclosure contains information relating to HIV, behavioral health, alcohol or drug abuse education, training, treatment, rehabilitation, or research, the following shall apply:

This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (Title 42 CFR Part 2 and Ch. 368x) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

Notice to Individual Requesting the Disclosure: Your signature below indicates that you understand that if the organization authorized to receive the information is not a health care provider or health plan, and the information disclosed is NOT protected by the Title 42 CFR Part 2 and Ch. 368x, then the released information may no longer be protected by the HIPAA Federal Privacy Regulations.

Signature of Patient or Legal Representative

Date Time

Printed name of Legal Representative

Relationship to patient

Signature of Individual Picking up Record

Relationship to patient

Please return this completed disclosure to: HIM Department/Waterbury Hospital 64 Robbins Street, Waterbury, CT 06721

For Office Use Only

CN3300A Rev. 11/5/2014 Page 2 of 3

Windham Hospital A Hartford HealthCare Partner

Phone: 860-456-6743 Fax: 860-456-6885

MR#:

Date Completed:

Pages Copied:

Initials:

04507W

AUTORIZACION PARA DIVULGAR / OBTENER INFORMACION DE SALUD

Sujeto a las declaraciones impresas al dorso, yo, el paciente o el representante legal que suscribe, por la presente autorizo el uso y divulgaciOn de la informaci6n de salud que incluye, si corresponde, la informaci6n relacionada con el diagnOstico o tratamiento de una enfermedad mental, abuso de drogas y/o alcohol e informaciOn relacionada con el VIH.

Nombre del paciente: Fecha de nacimiento:

COMPLETAR PARA QUE EL WINDHAM HOSPITAL DIVULGUE FILL OUT FOR WINDHAM HOSPITAL TO DISCLOSE

COMPLETAR PARA QUE EL WINDHAM HOSPITAL OBTENGA FILL OUT FOR WINDHAM HOSPITAL TO OBTAIN

Autorizo al Windham Hospital a divulgar informacion de salud a:

Nombre:

Autorizo a

a divulgarle informaci6n de salud al

departamento Instituci6n:

Direcci6n: Windham Hospital 112 Mansfield Avenue Willimantic, CT 06226

Persona de contacto: Telefono No.:

Fax No.: Telefono No.:

Metodo de divulgaci6n:

0 Correo 0 Verbal 0 Entregado CI Revision

Fax:

Las fechas de servicio y el o los tipos de informacion que se usara o divulgara son como sigue:

Fecha(s) de tratamiento:

0 Historial fisico 0 Resumen de alta 0 Registro DE 0 Reportes quirOrgicos

0 Reportes laboratorio 0 Reportes radiologia 0 Peliculas radiologicas 0 Reportes patologia

CI Registros facturaci6n 0 Expediente completo 0 Otro

0 Consultas

0 Reportes de progreso

El prop6sito de esta divulgaciOn o uso es por los siguientes

0 Medico 0 Legal 0 Incapacidad 0 Seguro 0 Solicitud del paciente

motivos:

0 Otro

• Esta autorizaciOn sera valida por un periodo de un alio a partir de la fecha de abajo. Entiendo que puedo revocar esta autorizacion en cualquier momento notificando a Health Information Management (Manejo de la informaci6n de salud) por escrito. Entiendo que la revocation no se aplicara a la informaci6n que ya ha sido liberada en respuesta a esta autorizaciOn.

• Entiendo que bajo la ley en vigencia la informed& divulgada bajo esta autorizacion puede quedar sujeta a divulgaciOn posterior por el destinatario y, por lo tanto, puede ya no estar protegida por los reglamentos federales de privacidad.

• Entiendo que mi tratamiento o la continuaciOn de mi tratamiento por parte del Windham Hospital no este condicionado de forma alguna por que yo firme o no firme esta autorizaciOn y que puedo rehusarme a firmarla.

• Entiendo que puedo inspeccionar o copiar la informed& a ser usada o divulgada. Entiendo que existe un cargo por las copias. • El padre o tutor legal debe firmer esta autorizaciOn si el paciente es menor (tiene menos de 18 anos) o tiene un tutor legal. • Los menores que reciben un tratamiento por abuso de drogas o tratamiento para enfermedad venerea pueden firmer su propia autorizaciOn.

Autorizacion puede ser enviada a: Health Information Management 112 Mansfield Avenue Willimantic, CT 06226

Firma del paciente o representante legal Fecha Hora

Testigo

Relation con el paciente: 0 Mismo 0 Padre 0 Representante

❑ Conservador 0 Albacea del estado ❑ Poder notarial 0 Otro

Si esta firmada por el Representante legal, adjuntar la documentaci6n apropiada para verificar autoridad.

WH Forms 590119 Rev. 10-13, 1-15 Printed by the Digital Print Center @ HH 1 of 2 Pages

R Windham " Hospital A Hartford HealthCare Partner

Phone: 860-456-6743 Fax: 860-456-6885

I I MR#: Date Completed: Pages Copied: Initials:

104507W

INFORMACION RELACIONADA CON EL VIH En caso de que la informaci6n liberada constituya informacion confidencial relacionada con el VIH protegida bajo la ley de Connecticut: Esta informaci6n le ha sido divulgada de registros cuya confidencialidad este protegida por la ley estadual. La ley estadual le prohibe hacer ninguna divulgacion adicional de la misma sin el consentimiento especifico por escrito de la persona a la que pertenece, o de otra forma permitida por dicha ley. Una autorizacion general para la liberacion de informaci6n medica o de otra indole NO es suficiente para este proposito.

INFORMACION PSIQUIATRICA En caso de que la informaci6n liberada constituya informacion confidencial psiquiatrica protegida bajo la ley de Connecticut: Esta informaciOn le ha sido divulgada de registros cuya confidencialidad este protegida por la ley estadual. La ley estadual le prohibe hacer ninguna divulgaciOn adicional de la misma o usarla para cualquier prop6sito que no sea el indicado arriba sin el consentimiento especifico por escrito de la persona a la que pertenece, o de otra forma permitida por dicha ley.

REGISTROS DE ABUSO DE DROGAS Y ALCOHOL En caso de que la informaci6n liberada este protegida por las HHS Confidentiality of Alcohol and Drug Abuse Patient Records Regulations (Reglamentos para la confidencialidad de registros de pacientes de abuso de alcohol y drogas de HHS): Esta informaciOn le ha sido divulgada de registros protegidos por las reglas federales de confidencialidad (42 CFR parte 2). Las reglas federates le prohiben hacer ninguna divulgacion adicional de esta informaci6n a menos que la divulgacion adicional este expresamente permitida por el consentimiento escrito de la persona a la que pertenece o permitido de otro modo por 42 CFR Parte 2. Una autorizacion general para la liberaciOn de informaci6n medica o de otra indole NO es suficiente para este prop6sito. Las reglas federales restringen todo use de la informaci6n a la investigacion criminal o el procesamiento de cualquier paciente de abuso de alcohol o drogas.

WH Forms 590119 Rev. 10-13, 1-15 Printed by the Digital Print Center t HH 2 of 2 Pages

ri Windham 1̀1 Hospital A Hartford HealthCare Partner

11

MR#:

Date Completed: Pages Copied: Initials:

Phone: 860-456-6743 Fax: 860-456-6885

104507W

AUTHORIZATION TO DISCLOSE/OBTAIN HEALTH INFORMATION

Subject to the statements printed on the back, I, the undersigned patient or legal representative, hereby authorize the use and disclosure of health information including, if applicable, information relating to the diagnosis or treatment of mental illness, drug and/or alcohol abuse and HIV related information.

Patient Name:

Date of Birth:

FILL OUT FOR WINDHAM HOSPITAL TO DISCLOSE FILL OUT FOR WINDHAM HOSPITAL TO OBTAIN

I authorize the Windham Hospital to disclose health information to:

Name:

I authorize

To disclose health information to Dept:

Facility:

Windham Hospital 112 Mansfield Avenue Willimantic, CT 06226

Contact Person:

Address:

Tele#:

Fax#: Tele#:

Fax: Method of Disclosure:

0 Mail 0 Verbal 0 Pick-up 0 Review

The dates of service and the type(s) of information to be used or disclosed are as follows:

Date(s) of Treatment:

0 History & Physical 0 Discharge Summary LI ED Record 0 Operative Reports 0 Consultations La Laboratory Reports CI Radiology Reports U Radiology Films t0 Pathology Reports 0 Progress Reports

LI Billing Records 0 Entire Record U Other

The purpose of this disclosure or use is for the following reason: CI Medical 0 Legal 0 Disability 0 Insurance CI At the request of the patient 0 Other

• This authorization will be valid for a period of one year from the date below. I understand that I may revoke this authorization at any time by notifying the Health Information Management Department in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization.

• I understand that under applicable law the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal privacy regulations

• I understand that my treatment or continued treatment by Windham Hospital is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it.

• I understand that I may inspect or copy the information to be used or disclosed. I understand there is a charge for copies.

• The parent of legal guardian must sign this authorization if the patient is a minor (under age 18) or has a legal guardian.

• Minors receiving drug abuse treatment or treatment of venereal disease may sign their own authorization.

Authorization can be sent to: Health Information Management 112 Mansfield Avenue Willimantic, CT 06226

Signature of Patient or Legal Representative

Date Time

Relationship to patient: U Self 0 Parent 0 Guardian Witness

0 Conservator 0 Executor of Estate 0 Power of Attorney 0 Other If signed by the legal Representative attach appropriate documentation to verify authority

WH Forms 590118 Rev. 2/2014, 4/14 Printed by the Digital Print Center @ HH 1 of 2 Pages

Windham Hospital A Hartford HealthCare Partner

H

MR#: Date Completed: Pages Copied: Initials:

Phone: 860-456-6743 Fax: 860-456-6885

104507W

HIV RELATED INFORMATION In the event that information release constitutes confidential HIV related information protected under Connecticut Law: this Information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

PSYCHIATRIC INFORMATION If the event that information released constitutes confidential psychiatric information protected under Connecticut Law: This information has been disclosed to you from records whose confidentiality is protected by state law. State law Prohibits you from making any further disclosure of it or of using it for any purpose other than that indicated above without The specific written consent by the person to whom it pertains, or as otherwise permitted by said law.

DRUG AND ALCOHOL ABUSE RECORDS In the event that information released is protected by the HHS Confidentiality of Alcohol and Drug Abuse Patient Records Regulations:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly Permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general Authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict Any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

WH Forms 590118 Rev. 2/2014, 4/14 Printed by the Digital Print Center @ HH 2 of 2 Pages

first

SS# Mdide Malden Name

Patient's Name: Last

Birthdate:

Address:

JOHNSON MEMORIAL HOSPITAL Health Information Services Department

201 Chestnut Hill Road • 1'0 Box 860 • Stafford Springs. Cl 06076 r8601 684-8242 • fax: i8601 684-8239

AUTHORIZATION FOR RELEASE OF INFORMATION

MR #:

Completed:

Initials:

Fee:

Phone Home:

Work:

Comments:

Cell:

The dates of service and the type(s) of information to be used or disclosed is as follows:

The information may be disclosed to and used by the following:

Name:

Address:

Tel. #: Fax #:

The purpose of this disclosure or use is for the following reason:

J Medical/Continuing Care Appointment Date:

Legal -1 Disability Social Security J Insurance J Workman's Comp

C.:1 Other (please specify)

Date(s) of Treatment:

J History & Physical J Operative Report J Vascular Report

ED Record -1 Radiology Report J Laboratory J Pathology Report

J Other

J Discharge Summary J Consultation J Cardiology J Neurology Report J Behavioral Health J Mental Health Evaluations J Psycho/Social Assessments

I hereby authorize the Medical Records Department of Johnson Memorial Hospital to disclose/obtain tfie information from the specified periods) o hospitalization or outpatient encounter as indicated below

PLEASE CHECK AND INITIAL EACH TYPE OF INFORMATION THAT MAY BE RELEASED:

MEDICAL J SURGICAL OBSTETRIC J NPArliCRN J REHABILITATION (PT OR CARDIAC)

J PSYCHIATRIC RECORDS • In the event that information released constitutes privileged psychiatric - patient communications The confoentality of tras record is required under -- Chapter 899 of 11T Connecticut General Statutes This material shall not be transmitted to anyone without written auMonzabon as provided in the aforementioned statutes

1J DRUG AND ALCOHOL ABUSE RECORDS • In the event that cloimation released is protected by the NHS Confidentiality of Alcohol arid Drug Abuse Patient Records regulations_ This information ;as been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 21 The federal rules prohibit you from nraking any fur tier disclosure of this infomiabon unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 A general authonzatron for release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

-I HIV RELATED INFORMATION - in the event that information released constitutes confidential F4A1 related infonnabon protected under Connecticut Law The confrdenti record is required under chapter araa of the Connecticut General Statutes. This matenal shall not be transrrinted to anyone without written authorization as provided in die aforementioned statutes. A general aurhonzatior, for release of tried-cat or other intormation is NOT sufficient for this PorOese

I understand that my treatment or continued treatment by Johnson Memorial Hospital is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign rt. I understand that under applicable law the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no

iger he protected by federal privacy regulations. I understand that I may inspect or copy the information to be used or disclosed. I understand that Johnson Memorial Hospital may receive compensation for copy and processing fees related to the use/disclosure of my health information under this authorization.

This authorization will be valid for days (90 days if lett blank) tram the date of my signature. I understand that I may cancel this authorization at any time by notifying the Health Information Management Department in writing, but if I do it will not have any effect on actions that the hospital took before it received the cancellation.

Please: J Fax J Mall _1 Will Pick up on

X

is

Call: J Home, J Work. J Cell when ready

Signature of Patient ar Legal Representative Date Witness

It signed by the Legal Representative, indicate your relationship to the patient below:

-I Parent/Guardian J Conservator J Executor of Estate J Power of Attorney J Next of kin Other

The patient's parent or guardian must sign this authorization if the patent is a minor (under age 181 or has a legal guardian Mirrors hong drug abuse treatment or treatment of venereal disease may sign their own authorization

1111 FORM NO 15-7181 NEW 11:2004

DDLESEX 1-10SKI A L

Nota para el solicitante de reqistros: Puede aplicar una tarifa de USD$ 0.65 por pagina para copias del reoistro medico.

Autorizacion para divulgar u obtener informacion

Nombre del Paciente: Fecha de nacimiento / /

(09/

20

11

)CC

23

6

Por la presente autorizo al Middlesex Hospital / Middlesex Sistema de Salud para divulgar u obtener toda la informaciOn medica respecto al tratamiento del paciente al que se hace referencia arriba que incluye con informacion relacionada con el diagnOstico o tratamiento de enfermedad mental o de abuso de drogas o alcohol e informacion confidencial relacionada con el VIH.

Nombre de personas a quien se revela Ia informaciOn:n Los reaistros pueden ser divulqados a: ri Fueron obtenidos de:

Nombre: No. telefOnico:

Direccion:

Ciudad: Estado: Codigo postal:

Indicar Ia preferencia de entreqa (seleccione uno)

0Corre ❑ En el lugar de recogida El InformaciOn electranicamente (E-mail) (Por favor, indique la direcci6n de correo electrOnico)

Descripcion de los propOsitos de la divulqacion solicitada:

0 Personal

0 Medico de atenciOn primaria

❑ Consulta

❑ Nuevo medico

❑ Reclamo de seguro medico ❑ Indemnizacion a trabajadores

❑ Incapacidad del Seguro Social

❑ Seguro de vida

❑ Abogado

❑ Otro:

Descripcion de Ia informacion que se usara o revelara.

Fecha(s) especifica(s) del/de los tratamiento(s)

❑ Teoria (resumen del expediente clinico, historial y reporte ffsico, informe quirOrgico, informe de alta de hospitalizacion,

consultas, laboratorio, radiologia)

❑ Cirugia (informe quirOrgico, informe de patologia)

❑ Resultados de examenes (laboratorio, radiologia, cardiologia, neurologia, respiratorios)

❑ Notas de terapia (fisica, ocupacional, de habla, quimioterapia, radiaciOn)

❑ Registro completo de urgencias

❑ Registro completo - especifique las fechas de atenci6n medica: a

❑ Otro

Entiendo que el Middlesex Hospital no condicionara mi tratamiento, pago, inclusion o elegibilidad para recibir beneficios a la firma de esta autorizacion. Reconozco que firmo esta autorizaciOn voluntariamente y nadie me ha coaccionado ni presionado para hacerlo. Comprendo que puedo anular esta autorizacion en cualquier momento a traves de notificaciOn por escrito dirigida al Middlesex Hospital. Entiendo que no podre anular esta autorizacion en caso de que el Middlesex Hospital haya tornado acciones basado en ella o si la autorizaciOn se obtuvo como condici6n para conseguir cobertura medica. Comprendo que Ia informacion protegida de salud revelada bajo esta autorizaciOn puede ser nuevamente divulgada por el beneficiario y no estar ya protegida por las regulaciones federales de privacidad. Tambien comprendo que si Ia informacion protegida de salud revelada bajo esta autorizacion es informackin confidencial relacionada con el VIH o sida o informackin relacionada con abuso de drogas o alcohol, el beneficiario no podra divulgar nuevamente esta informacion segim Ia Ley del Estado de Connecticut. A menos de que esta autorizacion sea anulada, expirara en la siguiente fecha, evento o condicion: Si no logro especificar una fecha de vencimiento, evento o condici6n, esta autorizacion expirara en un aflo.

Firma Firma del paciente o de la persona que otorga la autorizacion a nombre del paciente

Si firma el representante legal, indique su relacion con el paciente abajo mencionado y adjunte una copia de Ia documentacion:

0 Tutor El Poder ❑ Ejecucion del Estado ❑ Otro:

PARA USO DE SALUD CONDUCTUAL SOLAMENTE

AVISO

Reqistro psiquiatricos v comunicaciones

En caso de que la informaci6n divulgada constituya comunicaci6n privilegiada entre psiquiatra y paciente:

"La confidencialidad de este registro es ordenada bajo el capitulo 899 de las Leyes Generales de Connecticut. Este material no sera transmitido a nadie sin el consentimiento por escrito ni otra autorizaci6n, segiin lo establecido en las !eyes antes mencionadas." (§ 52-146i)

Reuistros de abuso de drogas v alcohol

En caso de que la informacion divulgada este protegida por las regulaciones de confidencialidad de los registros de pacientes que abusan de drogas y alcohol de los HHS:

"Esta informacion le ha sido revelada de registros protegidos por las normas federales de confidencialidad (Titulo 42 del CFR, parte 2). Las normas federales prohiben que usted divulgue a otros esta informacion a menos que este permitido expresamente bajo el Titulo 42 del CFR, parte 2. Una autorizaci6n general para la divulgaci6n de informacion medica o de otra informacion NO es suficiente para este proposito. Las normas federales restringen el use de la informaci6n en investigaciones delictivas de un paciente o par enjuiciar a un paciente que abusa de drogas o alcohol." (42 C.F.R. § 2.32)

Informacion relacionada con el VIH

En caso de que la informaci6n divulgada constituya informacion confidencial relacionada con el VIH, protegida bajo la Ley de Connecticut:

"Esta informacion le ha sido revelada de registros cuya confidencialidad este protegida por la ley estatal. La ley estatel prohlbe que revele la informacion a otros sin el consentimiento por escrito especifico de la persona a la que pertenece la informaciOn o segun lo permita la ley. Una autorizacion general para la divulgaciOn de informacien medica u otra informacian NO es suficiente para este proposito". Leyes Generales de Connecticut, seccion 19a-585(a)

❑ Servicios de consulta Middlesex Hospital Center for Behavioral Health 28 Crescent ST Middletown, CT 06457

❑ Programas de tratamiento diurno Middlesex Hospital 28 Crescent ST Middletown, CT 0645

❑ Pacientes externos Middlesex Hospital Center for Behavioral Health 28 Crescent ST Middletown, CT 0645

❑ Programa de defensa a la familia Middlesex Hospital Center for Behavioral Health 28 Crescent ST Middletown, CT 0645

&MI DDLESEX Note to Requestor of Records: There may be a $.65 per page charge for copies of the medical record.

Authorization to Release or Obtain Information

I hereby authorize Middlesex Hospital / Middlesex Health System to release/obtain all medical information with respect to the treatment of the above-referenced patient, including information relating to diagnosis or treatment of mental illness or drug or alcohol abuse and for confidential HIV related information.

The Name or Specific Identification of Persons to Whom Disclosure: El Records may be released to Obtained from:

Name: Phone No.:

Address:

City: State: Zip Code:

Indicate Delivery Preference (select one)

ElMail ElOn-site pick-up 0Email (Please provide email address)

Description of the Purposes of the Requested Disclosure:

El Personal

❑ Primary Care Physician

0 Consultation

❑ New Physician

El Medical Ins. Claim

0 Workers' Comp

El Social Security Disability.

0 Life Insurance

0 Attorney

0 Other:

Description of the Information to be Used or Disclosed.

Specific Date(s) of Treatment(s)

0 Abstract (face sheet, history and physical, operative report, discharge summary, consultation, laboratory, radiology)

O Surgical (Operative Report, Pathology Report)

El Test Results (lab, radiology, cardiology, neurology, respiratory)

O Therapy notes (physical, occupational, speech, chemo, radiation)

0 Complete Emergency Room Record

0 Complete Record - specify dates of care: to

0 Other

I understand that Middlesex Hospital will not condition treatment, payment, enrollment or eligibility for benefits based on my signing this Authorization. I acknowledge that I am signing this Authorization freely, and no one has coerced or pressured me to sign the Authorization. I understand that I may revoke this Authorization at any time by providing written notice to Middlesex Hospital. I understand that I may not be able to revoke this Authorization if Middlesex Hospital has taken action in reliance on the Authorization, or if the Authorization was obtained as a condition of obtaining insurance coverage. I understand that the Protected Health Information disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by the Federal Privacy Regulations. I also understand that if the Protected Health Information that is disclosed under this Authorization is confidential HIV/AIDS related information or alcohol or drug abuse related information, the recipient may not re-disclose that information under Connecticut State Law.

Unless otherwise revoked, this Authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this Authorization will expire in one year.

Date Signature of Patient or Person granting Authorization on behalf of patient

If signed by the Legal Representative, indicate your relationship to the patient below and attach a copy of the documentation:

El Conservator 0 Power of Attorney ❑ Executor of Estate 0 Other:

10-0

7-11 CC

2236

❑ Consult Services Middlesex Hospital Center for Behavioral Health 28 Crescent ST Middletown, CT 06457

FOR BEHAVIORAL HEALTH USE ONLY 111 Day Treatment Programs El Outpatient Middlesex Hospital Middlesex Hospital 28 Crescent ST Center for Behavioral Health Middletown, CT 0645 28 Crescent ST

Middletown, CT 0645

❑ Family Advocacy Program Middlesex Hospital Center for Behavioral Health 28 Crescent ST Middletown, CT 0645

DOB / / Name of Patient:

NOTICE

Psychiatric Records and Communications

In the event that information released constitutes privileged psychiatrist-patient communications:

"The confidentiality of this record is required under chapter 899 of Connecticut General Statutes. This material shall not be transmitted to anyone without the written consent or other authorization as provided in the aforementioned statutes." (§ 52-146i)

Drum and Alcohol Abuse Records

In the event that information released is protected by the HHS Confidentiality of Alcohol and Drug Abuse Patient Records regulations:

"This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient." (42 C.F.R. § 2.32)

HIV Related Information

In the event that information released constitutes confidential HIV related information protected under Connecticut Law:

"This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by law. A general authorization for the release of medical or other information is NOT sufficient for this purpose." Conn. Gen. Stat. 19a-585(a)

Eastern Connecticut Health Network, Inc.

MANCHESTER MEMORIAL HOSPITAL 71 Haynes Street, Manchester, CT 06040

ROCKVILLE GENERAL HOSPITAL 31 Union Street, Vernon, CT 06066

(Middle Initial) (Maiden/Other Name)

AUTHORIZATION FOR THE RELEASE OF INFORMATION

ATTACHMENT A

Patient Name: (Last) (First)

Date of Birth: Home Phone. Cell/Work Phone.

Complete Address (street or box #, city, state, zip)

This information is to be used for purpose of: ❑ Self ❑ Legal 0 Insurance 0 Treatment / follow up care EI Other

Method of Disclosure:

E] Mail 11 Pick Up (Photo ID Required)

Fax (Physician or Health Care Providers Only) Fax # (

I hereby authorize ECHN or its affiliates to release information to:

Name:

(Phone #)

Address: City/State: Zip.

Unless otherwise specified, only the following Information will be released.

ED Record Progress Notes I I Lab Results Stress Test

History & Physical Imaging CD LI EKG I I Patient Health Summary

❑ Discharge Summary Imaging Report 7 Pathology Report Li Echocardiogram

El Procedure/Operative Report 7 Behavioral Health I I PT/OT/Speech Notes Li Other

THE MEDICAL RECORDS ARE DATED: from - to -

Initial each type of information to release Drug & Alcohol Abuse Mental Health/Psychiatric (excluding Psychotherapy Notes)

MENTAL HEALTH RECORDS - In the event that information released constitutes privileged mental health patient communications, the confidentiality of this record is required under Chapter 899 of the Connecticut General Statutes. This material shall not be transmitted to anyone without written authorization as provided in the afore-mentioned statutes.

DRUG AND ALCOHOL ABUSE - In the event that information released is protected by the HHS confidentiality of Alcohol and Drug Abuse Patient Record regulations: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

AIDS OR HIV RELATED INFORMATION: This information has been disclosed to you from records protected by State Law. Connecticut State Law prohibits you from making any further disclosure without the written consent of the patient as otherwise permitted by said law.

Any records containing any of the above information requires signature from age 13 and older to sign for release of records.

I understand that I may refuse to sign this authorization without affecting my treatment or payment. Furthermore, I understand that once information has been disclosed subject to this authorization, the information may be subject to redisclosure and no longer be protected by state or federal law.

PATIENT SIGNATURE* DATE

"If THE PATIENT has NOT SIGNED this form, please indicate the relationship of the signator to the patient. _ Parent / Guardian _ Administrator / Executor of Estate _ Power of Attorney / Conservator Other Legal Representative-Specify: SIGNATURE OF REQUESTOR DATE

PRINT NAME OF REQUESTOR PHONE NUMBER

This authorization may be revoked in writing at any time, except to the extent that information has been obtained or released. Your rights to revocation may be found in the Notice of Privacy Practices. This authorization shall expire 12 months from the date of signature, or upon the following earlier event. Cond ion or Date

ROI Auth 9/11/2014