Authorization for Release of Information form - Danbury Hospital 2026

1. Click ‘Get Form’ to open the Authorization for Release of Information form in the editor.
2. Begin by filling out your personal information in the 'PATIENT INFORMATION' section. Include your name, date of birth, phone number, email address, and address details.
3. In the 'TO' section, specify the individual or institution you are authorizing to receive your information. Ensure you provide their complete address.
4. Select the type of information you wish to release by checking the appropriate boxes under 'INFORMATION REQUEST'. If applicable, initial next to any sensitive records such as Drug & Alcohol Abuse Records or Mental Health Records.
5. Indicate the date(s) of treatment relevant to your request and choose your preferred format for receiving the information.
6. Complete the authorization section by signing and dating the form. If signed by a representative, include their relationship to you.

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