Request for Medical Records/PHI

If you are a patient, guardian or representative of a patient, please complete the form as directed. All attorney, payor, provider, healthcare facility or other third-party requestors, please fax your requests to 860-585-3845. If you need assistance, please contact the Health Information Management Department at 860-585-3414, 8 a.m. to 4 p.m.

Request for Medical Records/PHI

Are you requesting records for?*
I am requesting records for another as the:*

Note: Please upload a copy of any legal documentation authorizing you to obtain these records in the designated section.

How would you like to receive your records?*
Phone
Phone
Phone
Phone

Confirm your email address below.

Patient Information

Phone

To process your request, identification is required. Please upload a picture of your identification such as a state issued driver's license or ID card, or any other documentation required to obtain records such as a Power of Attorney.

Drag and drop files here or

Covering the periods of health care:

Information to be disclosed/obtained:

Source of Information*
Select or enter value
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Enter your full legal name in the box below to electronically sign this document.

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