AUTHORIZATION OF RELEASE OF MEDICAL INFORMATION

Henry J. O'Neal, M.D., P.A.

3500 Fletcher Ave. Suite 301 Tampa, FL 33613 Phone: (813)971-2351 Fax: (813)971-1636
AUTHORIZATION OF RELEASE OF MEDICAL INFORMATION
To:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I hearby request a release of all my medical records to include all: (check the boxes for all that apply)

Progress notes (past 2 years)Labs (past 2 years)Consults (past 2 years)Diagnostic studies includes (x-ray, radiology, colonoscopy, ultrasoungs (past 7 years)
Henry J. O'Neal, M.D., P.A.*
Patient Name:*
Date of Birth:

MonthDayYear
Date
Patient Signature
Date:

MonthDayYear
Date
Witness Signature
Expiration Date: Six Months
Should be Empty:

Henry J. O'Neal, M.D., P.A.