I hereby authorize Academic Associates in Allergy, Asthma, and Immunology and its entities or agents to permit inspection, copying, and/or release of health information compiled in the ordinary course of business in connection with the following:
Please correct the errors described below.
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.
PLEASE INCLUDE NAME, FAX NUMBER, AND FULL MAILING ADDRESS
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.
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.