A Connecticut Nonprofit Organization dedicated to helping our first responders and veterans.

Please complete and submit the authorization for release of information form below IF APPLICABLE

Patient Information

Patient Name

First Name

Last Name

Date of Birth

YYYY

Phone Number

(###)

###

####

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

Dates of Service from:

Date

YYYY

Dates of Service through:

Date

YYYY

Select type of treatment

Information may be disclosed to:

Select

Name of Individual or Facility

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

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

Medical

Legal

Disability Insurance

At the request of the patient or legal representative

Other (specify)

I understand that my treatment or continued treatment by Honor Wellness Center, Inc. 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 electronic 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 any time by notifying Honor Wellness Center, Inc. in writing, but if I do it will not have any effect on actions that the release took before it received the cancellation. I understand that Honor Wellness Center, Inc. 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 General Statutes at $0.65 cents per page.

By entering your full legal name below you acknowledge that you have read this form in its entirety and that you authorize Honor Wellness Inc. to release the information that you have indicated to the person or entity that you have listed herein.

Date

YYYY

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 ia not sufficient for this purpose.

Honor Wellness Center

Please complete and submit the authorization for release of information form below IF APPLICABLE

Honor Wellness Center is a nonprofit organization in Connecticut