Medical Record Release

Patient Name:

Date of Birth:

Address:

City:

State:

Zip Code:

Phone Number:

I authorize the records release of the following information:

*Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information.

All Medical Records

Laboratory/Pathology Reports

X-Rays/Radiology Records

Pharmacy/Prescription Records

Billing Records

Office visit and General Notes

Please send the requested records to our office:

Infectious Diseases Consultants of the Treasure Coast
Address: 3735 11th Circle, Suite 201 Vero Beach, Florida 32960
Phone: (772) 299-7009
Fax: (772) 562-7138

The information requested may be used for purposed of my cotuineheat care. I understand that after the custodian of records discloses my health care information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign the authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment or eligibility for benefits unless allowed by the law. By signing w, I represent and warrant that i have the authority to sign this document and authorize the use and disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit or otherwise restrict my ability to authorize the user or disclosure of this protected health information.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name:

DOB:

Patient Signature:

Today's Date:

Your information will be encrypted.