Patient

Name of Patient

I authorize the named health care provider to release the information or records specified to the above referenced physician, 1250 S Tamiami Trail, Suite 301, Sarasota, FL 34239. 941-365-1321/Fax 941-365-4071 upon request in person or by mail to the address specified at the time of the request.

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RECORDS AUTHORIZED TO BE RELEASED:

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MM slash DD slash YYYY
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Records to be Released
____ Admission history and physical   ____ Lab reports
____ Discharge summary   ____ Radiological reports
____ Mammogram   ____ Consultation notes or reports
____ Office notes   ____ Bone density report
____ Outpatient records   ____ Colonoscopy with pathology
____ Immunization records   ____ Other
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(example, specific hospitalization or visit)

Authorization

• The office will contact all prior and/ or current physicians to obtain your medical records. • I am not required to sign this authorization and that my health care or payment for care will not be affected by my refusal. • Federal privacy regulations will no longer apply to the information disclosed, and that may redisclose the information. • I am entitled to receive a copy of this authorization. • A copy of this authorization may be utilized with the same effectiveness as an original. I understand that I can revoke this authorization at any time by writing to the health care provider, but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received. This authorization will expire one year from the date of the signature below. This information will be used for the purpose of Continuity of Care.
Name of Patient or Representative
MM slash DD slash YYYY
Clear Signature
Date
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