Authorization to Release Medical Records

Farahmand Plastic Surgery
Authorization for Disclosure of Protected Health Information Medical Records Release
Patient Name:
Name

First NameLast Name
Maiden Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby authorize the release of my protected health information from:
Name of Health Care Provider you are requesting records FROM:
Telephone number of the Health Care Provider you are requesting records FROM:
Fax:
My protected health information is to be released to:

Audrey Farahmand, MD

12411 Brantley Commons Ct. Fort Myers, FL 33907

Ph. #239-332-2388

Fax # 239-332-2382
For the Purpose of (Choose One)
***Specific Medical Records: (Please type the records Dr. Farahmand's Staff has instructed you to obtain)
I understand that these records may include information relating to:

*Acquired immunodeficiency syndrome (AIDS) / human immunodeficiency virus (HIV); or *Sexually Transmitted Diseases; or *Treatment for alcohol and/or drug abuse; or *Behavioral health service / psychiatric care

I understand that I may revoke this authorization at any time, except to the extent that action has been taken in reliance o this authorization or, if applicable, during a contestability period. The revocation must be made by completing Farahmand Plastic Surgery’s “Revocation of an Authorization to Release Protected Health Information” form. I also understand that I will not be denied or refused treatment if I refuse to sign this authorization. I further understand that the information used or disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by Federal and State privacy laws. I also understand that I have a right to receive a copy of this authorization if I request one. This authorization will expire “1” year from the date signed.
Signature of the Patient/Guardian/Legal Representative
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Farahmand Plastic Surgery

Authorization for Disclosure of Protected Health Information Medical Records Release

Patient Name: