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

1. Click ‘Get Form’ to open the HCH-551 document in the editor.
2. Begin by entering your personal information in the designated fields, including your name, date of birth, address, email, and phone number.
3. Specify the dates of service for which you are authorizing disclosure or obtaining information.
4. In the 'Information' section, check all relevant boxes indicating what health information you wish to disclose or obtain.
5. If there is any information you do not want released, indicate this in the provided section.
6. State the purpose for requesting this information in the designated area.
7. 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.
8. If applicable, provide details for where to send the requested information within UConn Health Center.
9. Review all entries for accuracy before signing and dating at the bottom of the form.

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