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.
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.