Request Medical Records from Another Office

Please complete this form if you would like PrimeCare of Coral Gables to request and obtain your medical records from another doctor, healthcare provider, hospital, facility, or organization.
PrimeCare of Coral Gables
370 Minorca Ave, 2nd Floor
Coral Gables, FL 33134
Tel: 305-443-3001
Fax: 786-235-8575

1. Patient information

Patient Last Name:

Patient First Name

Date of Birth:

Phone Number:

2. Where are the records coming from?

Doctor's Name:

Office Name:

Address:

City:

State:

Zip:

Phone Number:

Fax:

Email address

3. What Records Should We Request?

If other, specify:

4. Date Range of Records being requested:

Please select one:

Last 2 years All available records Specific date range:

From:

To:

5. Purpose of Request

Please select one:

Continuing medical care Transfer of care Upcoming appointment Care coordination Other:

Authorization for Release of Sensitive Information:

Some medical records may include information that is protected by additional privacy laws. Please indicate below if you specifically authorize the outside provider, office, hospital, facility, or organization listed in Section 2 to release these types of records to PrimeCare of Coral Gables.

If you do not select a category below, those specific records may not be released.

Mental Health Information I authorize the release of mental health or psychiatric treatment records, if applicable.

Yes No

Substance Use / Alcohol Treatment Information I authorize the release of records related to substance use disorder treatment or alcohol treatment programs, if applicable.

Yes No

HIV / AIDS / Sexually Transmitted Infection Information I authorize the release of information related to HIV status, AIDS diagnosis, HIV testing, or sexually transmitted infections, if applicable.

Yes No

I want all applicable records released, including any sensitive information listed above.

Yes No

Authorization Statement

I authorize the doctor, healthcare provider, hospital, facility, or organization listed above to disclose the medical records identified in this form to PrimeCare of Coral Gables.

I also authorize PrimeCare of Coral Gables, including its physicians, providers, staff, and representatives, to request, receive, review, and place these records in my medical chart for purposes of medical care, care coordination, administrative processing, and related healthcare operations.

I understand that the information released may include protected health information related to my medical care.

I understand that I may revoke this authorization at any time by submitting a written request to PrimeCare of Coral Gables and/or the provider or facility listed in Section 2. Revocation will not apply to information that has already been released in reliance on this authorization.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

Patient or Authorized Representative Signature

I confirm that I am the patient or the patient’s legally authorized representative

Signature

Printed Name

Date

If signed by someone other than the patient:

Relationship to Patient:

Legal Authority to Sign:

Phone Number of Representative:

Your information will be encrypted.