Request Medical Records

Patient Requests for Medical Records

Middlesex Health cares about your privacy. We have instituted policies and procedures that reflect our commitment to patient satisfaction and compliance with federal and state laws surrounding the release of protected health information (HIPAA).

Here you will find frequently asked questions as well as the necessary medical record request forms to download. All forms can be mailed to:

Middlesex Health System
28 Crescent Street
Middletown, CT 06457
Attn: Release of Information Unit

You may also fax the request to 860-358-6366 or e-mail it to


Frequently Asked Questions

Q. How do I request a copy of my health information?

A. You can request a copy of your health information by completing a Authorization to Release Information Form (Solicitud de Divulgación del Registro Médico del Paciente). You may submit the form by mail, in person, or email to:

Please mail your request to:

Middlesex Health 
28 Crescent Street
Middletown, CT 06457
Attn: Release of Information Unit

If you are submitting your request in person at Middlesex Hospital, you may do so from 8:00 a.m. to 4:00 p.m. Monday through Friday. The Release of Information Department is located on the first floor of the hospital.

Q. Who may request my health information?

A. The following people are authorized to request your health information on your behalf (proper identification will be required):

  • Health care representative if the patient is unable to sign (legal document must be provided.)
  • Parent (if the patient is younger than age 18)
  • Legal Guardian (proof of guardianship document must be provided.)
  • Administrator or Executor of the estate for deceased patients (copy of documentation required). In lieu of Executor documentation, a letter from the Probate Court indicating a Probate was not opened (authorization and proof by the next of kin is required).

Q. How much does it cost to obtain a copy of my health information?

A. Middlesex Hospital provides patients a copy of their medical record at no charge.

There is also no charge for copies of medical records for the following situations:

  • Medical records released for continued care to other healthcare providers.
  • Medical Records released to a patient's attorney or authorized representative for the purpose of supporting a Social Security claim or appeal and the request is accompanied by documentation of the claim or appeal.
  • Medical Records to support Worker’s Compensation cases as authorized by and to the extent necessary to comply with laws relating to Workers’ Compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

Q. When will I receive a copy of the medical record?

A. You will receive the medical records no later than 30 days from the date of your request.

Q. Can I obtain the medical records electronically?

A. Yes, Middlesex Hospital must provide you with a copy of your medical records in the electronic form and format you request, if it is readily producible in that form and format.

Q. Can I revoke a prior Request?

A. Yes, if the information has not already been released, you may revoke your request in writing by downloading and completing the Revocation of Release of Information Form  (Revocación de la autorización de divulgación de información) or you may revoke your request via a written letter. You may submit the form by mail, in person, or email to We will place the original request on hold unless previously acted upon.

Q. Who do I contact if I have questions?

A. If you have any questions, please contact the Health Information Services Dept. at 860-358-6222 or you may email the