AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION

Medical Records

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  • AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION

    To: ____________________________________________________________________________________________________

    I authorize and direct you to release my entire medical and billing file, including but not limited to all medical records, labs, billing ledger, physician orders, medications, etc.

    RECIPIENT INFORMATION:

    Address: 5401 S. KIRKMAN RD., SUITE 610, ORLANDO, FL 32819 * Phone: 407-299-8589 * Fax: 407-299-8549

    SPECIFIC DOCUMENTS TO BE RELEASED:

    ( ) ALL Records ( ) Face Sheet ( ) Discharge Summary ( ) History/Physical ( ) Operative Reports

    ( ) Consultation ( ) Labs ( ) Radiology Reports ( ) Progress Notes ( ) Physician Orders

    ( ) Cardiology Reports ( ) Nurses Notes ( ) Medications ( ) Itemized Bills

    I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information. ______ (initials) This request is authorized to include any federal and/or state protection under Florida Statutes 394.459(9) Psychiatric Information, 397.053/396.112 Drug and Alcohol Abuse Information 381,609 HIV and AIDS related conditions and/ or 397.50(3) records of minor client.

    PURPOSE FOR INFORMATION:

    ( ) Continued Medical Care ( ) Insurance ( ) Personal ( ) Current Litigation

    I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire in one year. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.  

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