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).

The Release of Information office is closed, effective 1/1/2023

Please find the necessary medical record request forms below to download and complete as well as several options to request medical records. 

Please refer to the Frequently Asked Questions  listed below for additional guidance.

You may request a copy of your health information by completing an Authorization. Release Information Form, (Solicitud de Divulgación del Registro Médico del Paciente).

You may submit the completed form:
By email to:
By fax to: 860-358-6366
By mail to: 
Middlesex Health
28 Crescent Street
Middletown, CT 06457
Release of Information Unit



You may also access your record via MyChart at

MyChart is Middlesex Health's patient information portal. It creates a single medical and financial record, so that you can see your medical information, interact with your providers' offices, and pay bills in one easy-to-access place.

Frequently Asked Questions

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 (a legal document must be provided.)
  • Parent (if the patient is younger than age 17)
  • 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).

Middlesex Health 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.

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

Yes, Middlesex Health can provide you with a copy of your medical records in electronic form and format you request, if readily producible in that form and format.

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 fax to: 860-358-6366, by email to:

or by mail to: 

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

We will place the original request on hold unless previously acted upon.

If you have any questions, please contact the Health Information Management Department at 860-358-6222 option four. Please leave a message with detailed information. A  staff member will return your call within one business day. You may also email your question to