Authorization for Release of Medical Records

Please be sure to hit SUBMIT at the end of this form

Patient First Name:

Patient Last Name:

Date of Birth:

Email address

EMAIL IS NEEDED TO IDENTIFY PAPERWORK

Telephone Number:

I further understand and acknowledge that in complying with my request for release, such disclosure will require Academic Associates in Allergy and Immunology to disclose, as provided under applicable federal law, Protected Health Information, as defined in 42 C.F.R. §160 et seq.

Information to be disclosed:

Complete Health Record

History and Physical Exam

Progress Notes

Radiology Reports

Abstract/Pertinent Information

Emergency Department Record

Laboratory Tests

Skin Test

Other

Please List if Other is selected

I UNDERSTAND THIS MAY INCLUDE INFORMATION RELATING TO THE FOLLOWING UNLESS EXPRESSLY EXCLUDED BY CHECKING THE BOXES BELOW:

Psychiatric Care (Behavioral Health)*

Treatment for Alcohol and/or Drug Abuse^

Genetic Testing

Sexually Transmitted Diseases (STDs)

Acquired Immunodeficiency Syndrome (AIDS) or infection with Human Immunodeficiency (HIV)

Who are we sending the records to??

You Doctor

How would you like them sent?

Email Fax Mail

There may be a fee

Doctor name

Doctor fax number

Doctor phone number

Email address you would like them sent to

Fax number you would like them sent to

Address you would like them sent to

I understand there may be a charge for copying my records as provided under federal and state law.

I understand this authorization may be revoked in writing at any time by sending written notification to Academic Associates in Allergy, Asthma and Immunology, ATTN: Privacy Officer, 13801 Bruce B. Downs Blvd., Suite 502, Tampa, Florida 33613, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked in writing, this authorization will expire 60 days from the date of execution. A photocopy or FAX of this document is valid as the original.

The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosures of the above information to the extent indicated and authorized herein.

Signature of Patient or Legal Representative

by typing your name above you consent to electronic signature

The patient information requested above may not be further disclosed to any party under any circumstances except with the patient's express written consent or as otherwise permitted by law. The information may not be used except for the need specified above.

*Except psychotherapy notes as provided under federal and state laws.

^PROHIBITION ON REDISCLOSURE: This information has been disclosed from medical records whose confidentiality is protected by federal and state law. Federal Regulations (42 CFR Part 2) prohibit the receiver from making any further disclosure of this information except with the specific written consent of the person who permits this. A general authorization for release of medical or other information if held by another party is not sufficient for this purpose.

Your information will be encrypted.

Authorization for Release of Medical Records

Please be sure to hit SUBMIT at the end of this form

I understand there may be a charge for copying my records as provided under federal and state law.

Please be sure to hit SUBMIT at the end of this form

Drs. Lockey, Glaum, Cho, & Pepper