HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENTINFORMATION PURSUANT TO 45 CFR 164.508

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENTINFORMATION PURSUANT TO 45 CFR 164.508
Please release the requested health information for the patient below to Bueno Pharmacy 2921 S. Orlando Drive STE 130 Sanford FL 32773. Tel: 855-283-6679 Fax: 407-878-3106.

Requested Information:
- Patient assessment
- Laboratory results
- Immunization records
- Medication treatment plan
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Today's Date

MonthDayYear
Date
I authorize and request the disclosure of all protected information for the purpose of review and evaluation by Bueno Pharmacy. I request that the designated record custodian disclose full and complete protected medical information including the following: Patient Assessment, Medication Treatment Plan, Immunization and Laboratory Records to Bueno Pharmacy. Records may be faxed to 407.878.3106.

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