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

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Patient Signature

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Witness Signature

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Patient Identification
Patient Name

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Date of Birth

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Social Security Number (SSN)
Date of Service
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

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Fax Number
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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

Practice Manager/Owner: Andrew Singer

FITCOFL@gmail.com

Fax Number: (727) 600-8025
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