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.

Are you requesting records for?

Self

Other

To be sent to a Healthcare Provider or Facility

Patient Information

Patient Name

Date of Birth

Telephone

Phone

Attach your ID or other documentation here

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.

Drop your files here

Covering the periods of health care:

From Date:

mm/dd/yyyy

To Date:

mm/dd/yyyy

Information to be disclosed/obtained:

Source of Information

Bristol Hospital

Bristol Health Medical Group

Both

eSignature of Patient/Legal Representative

Enter your full legal name in the box below to electronically sign this document.

Send me a copy of my responses

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