Medical Records Authorization Form

Digestive Medicine Associates

Please correct the errors described below.
Name of Entity / Provider

2140 West 68th Street, Suite 305 Hialeah, FL 33016-1815 Ph: (305) 822-4107 Fax: (305) 822-5086

This authorization shall be in force effect from the date signed below until (specify date) or (event that relates to the patient or the purpose of the use or disclosure) at which time this Authorization to use or disclose this protected health information exprires.

I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to Privacy Office at 2140 W 68th St, Suite 305, Hialeah, FL 33016. I understand that a revocation is not effective to the extent that Digestive Medicine Associates has relied on the use or disclosure of the protected health information. I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to:

  • Inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law) To the extent the state law provides greater access rights.
  • Refuse to sign this Authorization The use or disclosure requested under this Authorization may result in direct or indirect remuneration to the Digestive Medicine Associates from a third party.

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