Eileen C. Comia, M.D.
35 Jolley Drive Suite no.102 Bloomfield, CT 06002
Tel (860)242-2200 Fax (860)242-2212
AUTHORIZATION FOR RELEASE OF RECORDS
I, ______________________________________________ (Please Print Name) hereby authorize
Name of Physician/Facility: ____________________________________________________
Address: __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
To Release My Medical Records Including All Confidential and Communicable Disease-Related
Information To:
Eileen C. Comia, M.D.
35 Jolley Drive Suite no.102
Bloomfield, CT 06002
This authorization is for release of records of my care and treatment for the last ____ years inclusive.
I authorize release of all my records, including: Initials
HIV-Related Information Yes No _____
Drug and Alcohol Treatment Yes No _____
Mental Health Information Yes No _____
Sexual Assault & Domestic Violence Records Yes No _____
Reason for disclosure:
_________________________________________________________________________________
_________________________________________________________________________________
This authorization is valid for 6 months unless revoked in writing. It cannot be revoked retroactively
for information already released.
Patient’s Date of Birth: ________________ Social Security: ______________________
___________________________________________________ ________________________
(Signature of Patient or Legal Representative)
Date Signed
___________________________________________________
(Relationship to Patient)
DO NOT FAX TO OUR OFFICE.
