Patient Authorization for the Release of Medical Records

2323 Curlew Road Suite 2A, Dunedin, FL 34698

Phone (727) 600-8024

Fax (727) 600-8025
Patient Authorization for the Release of Medical Records
I, First Name* Last Name* , hereby authorize and direct the barer of any medical information on myself to release any and all medical records, in their entirety, to the physician or facility indicated below. This includes all medical records, in their entirety, to the physician or facility indicated below. This includes all information (including X-rays, ER records, ambulance reports, IME's, peer review records, hospital records, consultations, second opinions, etc) for any disease, disorder, mental or physical afflictions which I may have been treated for in the past, from the start of treatment to the present, in accordance with Chapter 397.017 and 455.211. Facsimile and/or electronic transmissions of records will be deemed acceptable, proving the records are complete and legible. In consideration of the above, I hereby release from responsibility for any liability arising from disclosure to the captioned holder of information, physician, or hospital.
Name*

First NameLast Name
Today's Date:

MonthDayYear
Date
Patient Signature*

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Patient Phone Number:*
Please enter a valid phone number.
Patient Identification
Patient Name*

First NameLast Name
Patient's Date of Birth:*

MonthDayYear
Date
Last 4 Digits of Social Security Number (SSN):*
Date of Service:
Date the patient was seen or treated at another facility for treatment or surgery.
Florida Statutes: Chapter 395.017 Hospital Licensing and Registration. Chapter 455.241 Health Care Practitioner.

Any health care practitioner licensed pursuant to (Florida Statutes) who makes a physical or mental examination of, or administers treatment to any person, shall upon request of such person or their representative, furnish in a timely manner, without delay for legal reviews, copies of all such reports and records relating to such examination and treatment.
Holder of Information
Physician/Hospital Name:
Physican/Hospital Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
PLEASE RELEASE INFORMATION TO THE FOLLOWING DOCTOR(S) AT THE ADDRESS LISTED ABOVE:

Bruce Kammerman, MD

Carmen Lynch, DC

Glenn Larsen, DC

Gennea Williams, DC, ND

Christopher Stenzel, DC

Paul Kalloghlian, DC

Alvaro “Varo” Betancourt, DC

J. Reinaldo Heredia, DC

Keegan Mente, DC

Practice Manager: Yudit Turino

FITCOFL@gmail.com

Fax Number: (727) 600-8025
*For Office Use Only: Licensed Provider's Signature:
Should be Empty: