Release of Information

Olive Health Primary Care 4912 West Trapnell Road, Plant City, Florida 33566 Phone: 813-417-4767 Fax: 888-814-0945 Email: Olivehealthfrontdesk@gmail.com Request for Records: email or fax back.Please return records as soon as possible to avoid delays in
Section A: This section must be completed for all Authorizations
Patient Name*
Patients Phone Number*
Last 4 digit SSN (optional)
Date of Birth*

MonthDayYear
Date
Facility Names and Addresses
There is some level of risk that a third party could see your information without your consent when receiving unencrypted electronic media or email. We are not responsible for unauthorized access to the PHI contained in this format or any risks (e.g., virus) potentially introduced to your computer/device when receiving PHI in electronic format or email. Note: In the event the facility is unable to accommodate an electronic delivery as requested, an alternative delivery method will be provided (e.g., paper copy

This authorization will expire after 180 days or on the following (please choose only one): Expiration Date:Expiration Event:
Expiration Date

MonthDayYear
Date
Expiration Event
Is this request for psychotherapy notes?If Yes, then this is the only item you may request on this authorization. You must submit another authorization for other items below

YesNo
Description of information to be used or disclosed All Pertinent Records includes those listed below

Medication List, Consultation, Discharge Instructions, Discharge Summary, Operative Report, Labor and Delivery Record, ER Report, Pathology Report, Specialty Test/Therapy Problem List, EKG Report, Physician Orders, History and Physical, Radiology Report, Progress Notes, Clinical / Laboratory Report
All types of information found in the records will be provided (if applicable), including information that may be viewed as sensitive, such as alcohol, drug abuse, genetic information, psychiatric, HIV testing, HIV results or AIDS information.
Specify any information you want to exclude:
I understand that:

1. I may refuse to sign this authorization and that it is strictly voluntary.

2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.

3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.

4. If the recipient is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be redisclosed. I

5.understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if ask for it.

6. I get a copy of this form after I sign it.
Section B: Is the request of PHI for the purpose of marketing and/or does it involve the sale of PHI?

YesNo
If yes, the health plan or health care provider must complete Section B

If no, skip to Section C
Will the Provider receive financial remuneration in exchange for using or disclosing this information? If yes, describe:
May the recipient of the PHI further exchange the information for financial remuneration?

YesNo
If yes describe
Section C: I have read the above and authorize the disclosure of the protected health information as stated.
Signature of PatientPatients Representative*

Clear
Today's Date*

MonthDayYear
Date
Print Name of Patients Representative
Relationship to Patient
Should be Empty:

Olive Health Primary Care 4912 West Trapnell Road, Plant City, Florida 33566 Phone: 813-417-4767 Fax: 888-814-0945 Email: Olivehealthfrontdesk@gmail.com Request for Records: email or fax back.Please return records as soon as possible to avoid delays in