OHA: Forms



Office of the Healthcare Advocate Release of Information

In order for OHA to advocate on your behalf, we may need to discuss your case, or request or share information and documents about your case, with involved parties.  This may include the insurance company(ies), doctor(s), hospital(s) or others.  In order to effectively and accurately evaluate options available to you, and work effectively on your case, your case manager will need all of the information about the issue that we're working on for you.

Privacy law requires that you give permission for anyone with your protected health information to release it.  Accordingly, we need you to complete and return a form authorizing OHA to discuss your case, receive and release any documents about your health care, and advocate for resolution with the involved parties.

The releases below are fillable pdf documents, which means that, if you have Adobe Acrobat (available here) installed on your computer, you can open the forms, fill in all of the necessary fields on the computer, and then print it to sign.  For those sections with the option to check next to the correct response, simply point the cursor to the desired location, and small "hand" will appear, indicating that you can click to enter a check mark.

Depending on the type of insurance you have, the law may have slightly different requirements for this release. 

If you do not have Medicare, you should complete and return this form:

OHA Authorization for Release of Information 

If you do have Medicare, we need to have one additional form completed by you.  The form below has the standard OHA release, in addition to this extra page required by Medicare:

OHA Authorization for Release of Information with Medicare

Examples of a completed Release of Information

Each of these documents has a page with instructions on how to complete it and what we need, but we understand that this can be confusing, so we've included samples of each form to illustrate what needs to be completed. You can find these samples here:

If you do not have Medicare  -  SAMPLE OHA Authorization for Release of Information

If you have Medicare - SAMPLE OHA Authorization for Release of Information with Medicare

Of course, if you have any questions about this process, or would like assistance completing these forms, please contact us by phone at (866) 466 - 4446, or email at healthcare.advocate@ct.gov.