"Freedom of Information Request Form" - Connecticut

Freedom of Information Request Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on July 1, 2005;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Freedom of Information Request Form" - Connecticut

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Record/Invoice Number: ____________
STATE OF CONNECTICUT
Office of Health Care Access
Freedom of Information
Request Form
Date: _____________
Information being requested:
(Please provide any and all specifics (i.e. Name of Facility,
Docket Numbers, etc.) and specify which parts you would like copied (if photocopying is involved).
Return Request by: (Please check one)
Mail
*Fax
Pick Up
(*If available as paper copy for requests smaller than 20 pages.)
Please complete the following information:
____________________________________________________________
Contact Person Name
____________________________________________________________
Company
____________________________________________________________
Street Address
____________________________________________________________
Town, State and Zip Code
____________________________________________________________
Telephone and Fax Number
____________________________________________________________
Email Address
THE FOLLOWING IS TO BE FILLED OUT BY OHCA ONLY
Your bill for this service is:
Files on CD @ $5.00 per file
$
Paper Copies @ $.25/page
$
Other (Misc.) Items:
$
Postage & Shipping Charges (if any)
$
Total Amount Due
$
Payment
: AFTER YOU RECEIVE YOUR BILL, please make checks payable to “TREASURER, STATE OF
CONNECTICUT” AND REMIT TO THE OFFICE OF HEALTH CARE ACCESS. 410 CAPITOL
AVENUE, MS#13HCA, P.O.BOX 340308, HARTFORD, CT 06134 AS SOON AS POSSIBLE.
PLEASE BE SURE TO INCLUDE ONE COPY OF THIS BILL WITH YOUR PAYMENT.
Note: If the copying charge is estimated to be over $10.00, prepayment may be requested
Revised July, 2005
Record/Invoice Number: ____________
STATE OF CONNECTICUT
Office of Health Care Access
Freedom of Information
Request Form
Date: _____________
Information being requested:
(Please provide any and all specifics (i.e. Name of Facility,
Docket Numbers, etc.) and specify which parts you would like copied (if photocopying is involved).
Return Request by: (Please check one)
Mail
*Fax
Pick Up
(*If available as paper copy for requests smaller than 20 pages.)
Please complete the following information:
____________________________________________________________
Contact Person Name
____________________________________________________________
Company
____________________________________________________________
Street Address
____________________________________________________________
Town, State and Zip Code
____________________________________________________________
Telephone and Fax Number
____________________________________________________________
Email Address
THE FOLLOWING IS TO BE FILLED OUT BY OHCA ONLY
Your bill for this service is:
Files on CD @ $5.00 per file
$
Paper Copies @ $.25/page
$
Other (Misc.) Items:
$
Postage & Shipping Charges (if any)
$
Total Amount Due
$
Payment
: AFTER YOU RECEIVE YOUR BILL, please make checks payable to “TREASURER, STATE OF
CONNECTICUT” AND REMIT TO THE OFFICE OF HEALTH CARE ACCESS. 410 CAPITOL
AVENUE, MS#13HCA, P.O.BOX 340308, HARTFORD, CT 06134 AS SOON AS POSSIBLE.
PLEASE BE SURE TO INCLUDE ONE COPY OF THIS BILL WITH YOUR PAYMENT.
Note: If the copying charge is estimated to be over $10.00, prepayment may be requested
Revised July, 2005