FLORIDA - RELEASE OF PATIENT INFORMATION AUTHORIZATION
HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENTINFORMATION PURSUANT TO 45 CFR 164.508
To Name of Healthcare Provider/Physician/Facility/Medicare Contractor:
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Regarding Patient Name
*
First Name
Last Name
Patient Date of Birth
*
Patient Social Security Number
*
I authorize and request the disclosure of all protected information for the purpose ofreview and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:
*
All medical records, meaning every page in my record, including but not limited to:office notes, face sheets, history and physical, consultation notes, inpatient, outpatientand emergency room treatment, all clinical charts, r ports, order sheets, progress notes,nurse's notes, social worker records, clinic records, treatment plans, admission records,discharge summaries, requests for and reports of consultations, documents,correspondence, test results, statements, questionnaires/histories, correspondence,photographs, videotapes, telephone messages, and records received by other medicalproviders.
All physical, occupational and rehab requests, consultations and progress notes.
All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry recordsand specimens; radiology records and films including CT scan, MRI, MRA, EMG,bone scan, myleogram; nerve conduction study, echocardiogram and cardiaccatheterization results, videos/CDs/films/reels and reports.
All pharmacy/prescription records including NDC numbers and drug informationhandouts/monographs.
I understand the information to be released or disclosed may include information relating tosexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or humanPage 1 of 2 immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosureof this type of information.
*
Yes, I understand and Agree
This protected health information is disclosed for the following purposes:
*
I understand the following: See CFR §164.508(c)(2)(i-iii)a. I have a right to revoke this authorization in writing at any time, except to the extentinformation has been released in reliance upon this authorization.b. The information released in response to this authorization may be re-disclosed to otherparties.c. My treatment or payment for my treatment cannot be conditioned on the signing of thisauthorization.Any facsimile, copy or photocopy of the authorization shall authorize you to release the recordsrequested herein. This authorization shall be in force and effect until two years from date ofexecution at which time this authorization expires.
*
Yes, I understand
Signature of Patient or Legally Authorized Representative
*
Name and Relationship of Legally Authorized Representative to Patient (Skip if not applicable)
Continue
Continue
Should be Empty: