Request Medical Records

Middlesex Hospital cares about your privacy and security. We have instituted policies and procedures that not only reflect our committment to patient satisfaction but also adhere to federal and state laws surrounding the release of protected health information.

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

Middlesex Hospital 
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 an Authorization to Release Information. Click here for the Spanish version of the Authorization to Release Spanish. You may submit the form by mail, in person, or email to

Please mail your request to:

Middlesex Hospital 
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 5:00 p.m Monday through Friday. The Release of Information Department is located on the first floor of the hospital.

Q. Who is authorized to sign for release of my health information?
A. The following people are authorized to sign for the release of your health information (proper identification may be required):

  • The patient (Not the spouse)
  • Power of Attorney 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.  Patients will be charged a $.65 fee per page for copies of their health information. The invoice will come from Healthport, a company contracted by the hospital. To reduce the cost, patients should consider requesting specific information rather than a complete record.

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

  • For releasing copies of health information directly to other healthcare providers.
  • Medical Records released to a patient's attorney or authorized representative if the record or part thereof is necessary for the purpose of supporting a claim or appeal under any provision of the Social Security Act 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.
  • Hospital may charge a patient the amount necessary to cover the cost of materials for furnishing a copy of an x-ray.

Q. When will I receive a copy of the medical record?
A. You will receive the medical records no later than 30 days from your request unless the record is located offsite and in that case it will be processed within 60 days.

Q. Can I access the medical records electronically?

A. Yes, by providing your email address on the Authorization Form you will receive information from the hospital's contracted vendor, Healthport.  Click here to download a copy of the Healthport Electronic Information Letter. This document will advise you of the computer requirements and other pertinent information.

Q. Can I revoke a prior authorization?

A. Yes, if the information has not been released, you may download and fill out the Revocation of Release of Information Form. Click here for the Spanish version of the Revocation of Release of Information Form (Spanish). 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 us at

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28 Crescent Street
Middletown, CT 06457

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