CONNECTICUT VALLEY HOSPITAL - ct 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient/Client's last name and first name in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Input the Date of Birth in the specified format. This helps verify the identity of the patient/client.
4. Fill in the MPI # and last 4 digits of SS# for tracking purposes. These fields are essential for processing your request.
5. Specify whether you wish to DISCLOSE or OBTAIN information by checking the appropriate box and providing details about the organization or person involved.
6. Indicate any limitations or restrictions on the information being shared, if applicable, to ensure compliance with privacy regulations.
7. Select the purpose of release by checking all relevant boxes, such as Evaluation/Treatment or Benefit Determination.
8. Choose what specific information you want released or obtained by marking the corresponding checkboxes.
9. Specify dates of treatment covered by this request, ensuring clarity on which episodes of care are included.
10. Finally, sign and date at the bottom of the form. If applicable, include a copy of any legal appointment documents.

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