• Authorization for Release of Information

  • Locations:

    Old Bull Athletics, Coral Gables
    169 Majorca Avenue
    Coral Gables, FL 33134

    Old Bull Athletics 2, Pinecrest
    8185 SW 117th Street
    Pinecrest, FL 33156

  • Authorization is not required for the Use or Disclosure of Information
    Related to Treatment, Payment, Healthcare Operations or if Required by Law or Rules
    HIPAA 143a-Authorization for Release of PHI 10-28-08

  • You May Refuse to Sign this Authorization

  • Section #4- Complete only if you selected “limited information”. I only authorize the release of information to the individuals/entities identified below by name:

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  • Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC.

  • Should be Empty: