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.
RECORDS AUTHORIZED TO BE RELEASED:
(example, specific hospitalization or visit)
• 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.