SACRED HEART GREENWICH STUDENTS

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

I authorize Murphy Medical Associates to disclose and release complete and legible copies of my child’s COVID-19 RT-PCR test results to Heather Elken BSN at Sacred Heart Greenwich if my child is a student at Sacred Heart.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

Prosperity Counseling, LLC/Prosperity Housing Inc.

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to, Karen Tyson, LADC, of Prosperity Counseling, LLC.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

SACRED HEART GREENWICH EMPLOYEES

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Sacred Heart Greenwich, Director of Human Resources.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

Parents’ Foundation for Transitional Living - EMPLOYEES

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Executive Director, Jennifer E. Fournier, JD, Parents’ Foundation for Transitional Living.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

Parents’ Foundation for Transitional Living - RESIDENTS

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Executive Director, Jennifer E. Fournier, JD, Parents’ Foundation for Transitional Living.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

WEST HAVEN FIRE DEPARTMENT

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the West Haven Fire Department.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

WEST HAVEN POLICE DEPARTMENT

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the West Haven Police Department.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

STAMFORD FIRE DEPARTMENT

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stamford Fire Chief.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

STAMFORD POLICE DEPARTMENT

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stamford Police Chief.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

STAMFORD POLICE DEPARTMENT

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stamford Police Chief.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

STRATFORD FIRE DEPARTMENT

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stratford Fire Chief.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

STRATFORD POLICE DEPARTMENT

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stratford Police Chief.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

DARIEN POLICE DEPARTMENT

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

 
I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Darien Police Chief.

I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.