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HCH-551 - Authorization to Obtain and or Disclose Health Information pdf.doc 2026

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The document is an authorization form from the University of Connecticut Health Center allowing patients to disclose or obtain their health information. It outlines the patient's rights regarding their health data, specifies the types of information that can be shared, and details the process for revoking consent. The form also includes legal disclaimers about confidentiality and conditions under which information may be disclosed.

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Click ‘Get Form’ to open the HCH-551 document in the editor.
Begin by entering your personal information in the designated fields, including your name, date of birth, address, email, and phone number.
Specify the dates of service for which you are authorizing disclosure or obtaining information.
In the 'Information' section, check all relevant boxes indicating what health information you wish to disclose or obtain.
If there is any information you do not want released, indicate this in the provided section.
State the purpose for requesting this information in the designated area.
Fill out the details of the person(s) or organization(s) to whom this information will be disclosed or from whom it will be obtained.
If applicable, provide details for where to send the requested information within UConn Health Center.
Review all entries for accuracy before signing and dating at the bottom of the form.

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