Skip to main content
  • (203) 618-4200
  • Schedule a Tour
  • Admissions
  • Careers
  • News
  • Family Updates
  • Medical Records Request Form
Nathaniel Witherell - The Finest in Senior CareNathaniel Witherell - The Finest in Senior Care DONATE / GET INVOLVED
  • About
  • Services
    • Short-Term Rehabilitation
    • Skilled Nursing
    • Memory Care
    • Caregiver Support
  • Lifestyle
  • Events & Newsletters
  • Schedule A Tour
  • Admissions
  • Careers
  • News
  • Family Updates
  • Blog
  • Contact Us
  • Donate / Get Involved

Medical Records Request Form

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

I, the undersigned patient or legal representative, hereby authorize Nathaniel Witherell to disclose or obtain health information, including if applicable, information relating to the diagnosis or treatment of mental illness, drug and/or alcohol abuse and confidential HIV related information regarding:
MM slash DD slash YYYY

Information may be(Required)
Mailing Address(Required)
Delivery Method(Required)
Fax to Healthcare Facilities/Providers only

The purpose of this disclosure or use is for the following reason:(Required)

The dates of service to be used or disclosed

Requested Information:(Required)
Please specify if you need specific reports only:(Required)

I understand that my treatment or continued treatment by Nathaniel Witherell is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. I understand that under applicable law the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal privacy regulations. I understand that I may inspect or request a copy of the information to be used or disclosed by the recipient.

This authorization will be valid for a period of one year from the signature date below. Medical records will only be released for dates of service which occur prior to the authorization date unless disclosure of a future service date is specifically authorized. I understand that I may cancel this authorization at any time by notifying Nathaniel Witherell in writing, but if I do it will not have any effect on actions that the release took before it received the cancellation.

Copy Fees: I understand that Nathaniel Witherell may charge a fee for copying and first class postage to the individual receiving the requested information. Copy fees will be applied in accordance with Connecticut Statute at $0.65 cents per page and $6.50 for an electronic copy.

MM slash DD slash YYYY
If not resident, state the relationship to resident/patient below (legal documentation required as applicable):(Required)

The confidentiality of psychiatric, alcohol, drug and HIV related records is required by Connecticut General Statutes and/or Federal Regulations 42 CFR, part 2. This information shall not be re-disclosed to anyone else without written consent or other authorization as provided in the Connecticut General Statutes and/or Federal Regulation 42 CFR, part 2. A general authorization for the release of medical information is not sufficient for this purpose.
This field is for validation purposes and should be left unchanged.

Support Your Hometown Seniors - Please Donate
Nathaniel Witherell - The Finest in Senior CareNathaniel Witherell - The Finest in Senior Care
70 Parsonage Road
Greenwich CT 06830
(203) 618-4200
  • About
  • Skilled Nursing
  • Short Term Rehab
  • Memory Care
  • Caregiver Support
  • Lifestyle
  • Events & Newsletters
  • Donate / Get Involved
  • Admissions
  • Schedule A Tour
  • Blog
  • Careers
  • News
  • Family Updates
  • Contact Us
  • Medical Records Request Form
  • Privacy Practices
  • Right To Request Health Information
  • Right To Access information
  • Town Of Greenwich
  • Medical Records Request
©2023 Nathaniel Witherell All Rights Reserved.
Support Your Hometown Seniors - Please Donate

Friends of Nathaniel Witherell

$
Select Payment Method
Personal Info

Billing Details

Donation Total: $50.00

The Friends of Nathaniel Witherell is a 501(c)(3) non-profit organization committed to raising funds and otherwise enhancing the quality of life for Nathaniel Witherell’s residents. Charitable contributions to The Friends of Nathaniel Witherell are fully deductible as allowed by law.

Take A Virtual Tour
Schedule a Tour

Fill out this form to schedule a tour