Instructions for Authorization Form

Please follow the directions below for completing the "Authorization to Disclose/Obtain Health Information" form

Print Authorization Form and complete the following information:

Name of Patient (please print)
Date of Birth
Phone #

Disclose Information to: (address where records are being mailed to or person records are being released to).

  • Provide fax # if records are to be faxed to a health care provider. Medical Records cannot be faxed to a private fax machine.

Purpose of Disclosure:

  • Please state the reason why the records are needed.

Information to be disclosed:

  • Please be as specific as possible to the type of records needed. Example: Labs, X-rays, E.R., Summary, etc.

Date(s) of Treatment: (Date(s) of records needed)

Disclosures Requiring Special Consent

  • Please write on the line provided below, the type of records that you do not want disclosed. (HIV/AIDS, Mental Health/Psychiatric, Drug, Alcohol/Abuse Treatment and Sexually Transmitted Diseases.)

Date and Sign.

  • Date of request cannot be before treatment date.
  • Minors (13-17) must sign for release of special material noted above.

After completing the form please mail to:

Lawrence & Memorial Hospital
Health Information Management - R.O.I.
365 Montauk Avenue
New London, CT 06320

or Fax to:

Lawrence & Memorial Hospital
Health Information Management (R.O.I.)
(860) 444-3760

If further assistance is needed in filling out the form, please contact:

Lawrence & Memorial Hospital, Health Information Management Dept., Release of Information - (860) 444-3704