Medical Release Form

Medical Release Form
(PATIENT - please enter the PHYSICIAN name FROM WHOM you would like us to get your records from:*

DOCTOR First NameDOCTOR Last Name
Please send us the following medical records on our mutual patient:

* Last Office Note

* Any Labs or Imaging

to: Pinellas Internal Medicine Associates

Fax: 727-544-8366

10707 66th St N Ste A, Pinellas Park, FL 33782
Patient Name:

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
THIS AUTHORIZATION has no expiration. I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric testing, physical abuse, or drug and alcohol abuse. This information is being released, received, and used for the purposes of coordinating my care, evaluating my needs, and/or providing services to me. I understand that I have the right to refuse to sign this authorization and that my treatment is not contingent upon whether or not I sign this authorization. It may be revoked at any time upon written notification by the signatory or client, but revocation has no effect on action previously taken.
PATIENT Signature:

Clear
Today's Date:*

MonthDayYear
Should be Empty: