Authorization for Release of Medical Information

Telephone: 772-348-0303
Fax: 772-348-0307

Patient’s Full Name

Date of Birth

Social Security

Phone Number

Work Number

I do hereby authorize

Phone Number

to release

DISCHARGE SUMMARY, HISTORY & PHYSICAL, PROGRESS NOTES, OPERATIVE NOTES, PATHOLOGICAL REPORTS, LABORATORY REPORTS, RADIOLOGY REPORTS, EKG/ECG/CARDIAC CATH, EMERGENCY REPORTS, AND/OR OTHER

I DO I DO NOT (please check one) authorize the release of information related to AIDS (acquired immunodeficiency syndrome) or HIV (Human Immunodeficiency Virus) Infection psychiatric care and/or psychological assessment and treatment for alcohol and/or drug abuse.

PURPOSE OF DISCLOSURE

I hereby authorize disclosure of the health information for the above patient. This authorization is valid for 12 months from date of the signature. I understand that I may cancel this request with written notification but will NOT affect any information of cancellation. I understand that the information used or disclosed may be subjected to re-disclosure by the person or class of persons or facility receiving it and would then longer be protected by FEDERAL regulations. I understand that the medical provider to whom this is authorized may not condition its treatment of me on whether or not I sign the authorization.

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

Individual or Guardian or Personal Representative (Please sign)

Today’s Date

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