HIPAA Release of Information Authorization Form
Patient authorizes Padgett Medical Center, LLC to request any and all medical records, x-rays, or any diagnostic testing results from any and all medical providers involved in my medical care past or present. Please forward any and all documents requested to the attention of the provider at this fax number below.
Tampa office Fax (813) 908-7711
Ocala office Fax (352) 369-0107
By signing this authorization, I understand that medical records released may contain
information related to HIV status, aids, sexually transmitted diseases, mental health, and alcohol abuse, etc. I understand that release of psychotherapy notes requires additional authorization. NOTE: If the information you are authorizing for release by signing this form involves alcohol or drug abuse, you must also sign a special authorization that is separate from this one, alcohol and drug abuse information is protected by federal law (FEDERAL REGULATIONS 42 CFR PART 2) and will not be shared with anyone else unless you sign a separate form.