Neurology and Physical Therapy Centers of Tampa Bay
Vincent Di Carlo, M.D. & Associates, P.A.
2835 W. De Leon Street, Suite 205 Tampa, FL 33609
TEL (813) 831-6622
FAX (813) 874-1936
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND INFORMATION
1. I authorize all health care providers, physicians, hospitals, medical staff and attorneys to furnish any and all information and medical records regarding me to Vincent Di Carlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay, including psychiatric, psychological and any mental health records.
2. I authorize Vincent Di Carlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay to release any and all information and medical records regarding me, including psychiatric, psychological and any mental health records, to those parties that are necessary to process and/or collect from my insurance claim(s), and/or other claims related to my healthcare services.
3. I authorize Vincent Di Carlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay to release any and all information and medical records regarding me, including psychiatric, psychological, and any mental health records to all healthcare providers involved in my care and their representatives, and to my attorney(s) and their representatives.
4. I Agree that this authorization will cover all medical services rendered, with no limitations on dates and history of injury and/or illness, until such authorization is revoked by me in writing.
5. I agree that a photocopy of this form may be used in lieu of the original.