Authorization for Disclosure of Health Information

I______DOB___ /____/____authorize Connecticut Nephrology Associates, LLC to Obtain/Release information as described below.

Please check appropriate box:

o  I would like my records forwarded to:

Connecticut Nephrology Associates, LLC, 455 Lewis Avenue, Suite 214, Meriden, CT 06451

- Dr. Irfan S. Chughtai

- Dr. Eileen D. Kehoe

- Dr. Mohammad A. Sharif

o  Please release my records to: ______

_____Complete Medical Records _____Hospital Records including Reports ____ X-ray Reports ___ Immunization _____ Laboratory Reports _____ Other (Specify)______

I also specifically authorize that any sensitive information regarding HIV/AIDS, substance abuse (alcoholism or drug abuse) and/or mental health may be used by or disclosed to the above referenced recipients.

I understand that if the authorized recipient is not a provider, health plan, or Glenwood System required complying with federal privacy standards, the information disclosed pursuant to this authorization may no longer be protected by the federal privacy standards. However, other state of federal law may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information.

Individual’s Rights Relations to This Authorization:

I understand that I must be provided with a copy of this form if I choose to sign it. I understand that I am under no obligation to sign this form and that Connecticut Nephrology Associates; LLC may not condition my treatment, payment, or enrollment/eligibility for benefits on my decision to sign this form. I understand that I may revoke my Authorization notifying Connecticut Nephrology Associates, LLC in writing of my revocation. To obtain information on how to revoke my Authorization or to receive a copy of my revocation, I am to contact Connecticut Nephrology Associates, LLC, 455 Lewis Avenue, Suite 214, Meriden CT 06451, I am aware that my revocation will not be effective as to uses and/or disclosures of my health information that the person(s) and or organization (s) listed above have already made in reliance on the Authorization.

Expiration Date: This Authorization is valid until ______, I have had an opportunity to review and understand the content of this Authorization form. By signing this Authorization, I am confirming that this accurately reflects my wishes.

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Individual’s signature and date Representative’s Signature and date

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Print Name Description of Representative’s Relationship

455 Lewis Ave., Suite 214, Meriden, CT 06451 Tel: (203) 237-6700 Fax (203) 237-6100 www.ctneph.com