This form authorizes PrimeCare of Coral Gables to obtain your medical records from your previous and/or other healthcare providers. Accessing these medical records will improve the quality and continuity of your healthcare and avoid the unnecessary and costly repetition of medical tests.
I request and authorize PrimeCare of Coral Gables to release healthcare information of the patient named above to:
This request and authorization applies to:
All healthcare information
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papillomavirus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma, venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
DISCLAIMER: 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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.