As required by the privacy regulations, this practice may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization. Under the Connecticut State Statues, this information cannot be transmitted to anyone else without explicit consent or through other authorizations as provided in the statues of the state of Connecticut.
I hereby authorize this office and any of its employees to use or disclose my patient health information to the following person(s) or entity.