Old Bull Athletics, Coral Gables169 Majorca AvenueCoral Gables, FL 33134
Old Bull Athletics 2, Pinecrest 8185 SW 117th StreetPinecrest, 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 RulesHIPAA 143a-Authorization for Release of PHI 10-28-08
Section #4- Complete only if you selected “limited information”. I only authorize the release of information to the individuals/entities identified below by name:
Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC.