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*
DOB
Address
City
State
Zip Code
SSN
Phone Number*
I hereby grant permission for you to release confidential health information about me, by

releasing a copy of medical record, or a summary or narrative of my protected health information

to Olive Health for
Patient Name
Name of Signer
Relationship
Signature

Clear
Should be Empty: