• 618 West Avenue. Norwalk, CT 06850

  • HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508

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  • All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits for the period    Pick a Date   to  Pick a Date .

  • I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.

  • This protected health information is disclosed for the following purposes:

    FOR CONTINUITY OF HEALTHCARE
  • This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.

  • You are authorized to release the above records to the following medical personnel/facility and/or representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:

  • Circle Care Center

    Physician or Healthcare Provider

    618 West Avenue

    Norwalk, CT 06850-4008

    Phone: 203-852-9525

    Fax: 203-854-0371

  • I understand the following: See CFR §164.508(c)(2)(i-iii)

    a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.

    b. The information released in response to this authorization may be re-disclosed to other parties.

    c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

     

    Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until one year from date of execution at which time this authorization expires.

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  • THIS MEDICAL RELEASE EXPIRES ONE YEAR FROM DATE OF SIGNATURE

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