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Authorization to Obtain and/or Disclose Medical Information Form
Please print and submit the following form for all requests for medical records. Be advised that medical records are only maintained by Connecticut state law for 7 years from the date of withdrawal or graduation from Central Connecticut State University.
Please expect normal processing time for all requests to take at least 30 days. All efforts will be made to process requests as quickly as possible. If we are unable to locate your record, we will notify by that time. Please request your record from your physician when possible as we may no longer have your record.
You can email the form to firstname.lastname@example.org, fax to (860) 832-2579, drop the form off in person to Student Wellness Services in Marcus White Annex, or mail to the following address:
Student Wellness Services
Marcus White Annex
1615 Stanley Street
New Britain, CT 06053