Authorization to Disclose Medical Records

ROSABEL M BENCOMO M.D P.A

6840 SW 40th Street, Suite 209, Miami, FL 33155

Toll Free: (877) 479-1479 | Office: (786) 222-8807 | Fax: (305) 763-8379
Authorization to Disclose Medical Records

**(Required by the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 and 164)**
Full Name*

First NameLast Name
Email*
example@example.com
Date of Birth*
mm/dd/yyyy
Address*

Street Address

Street Address Line 2

CityState

Zip Code
This form is to provide Rosabel M Bencomo MD PA staff / MDteleMe staff with a means to request the use and/or disclosure of an individual's protected health information.
Who you are...*

I am the client and hereby authorize the use or disclosure of health information, including protected health information, about me as described below.I am the client’s representative, understand, and agree to the provisions of this authorization on behalf of the patient.
Phone Number*
Legal Guardian Information*
By signing this form, I authorize the release of health information, including Protected Health Information.
I authorize Rosabel M Bencomo MD PA/ MDteleMe to:*

Obtain From:Disclose to:
Name of the entity medical records are been request from or send to:*
INFORMATION MAY BE DISCLOSED BY: Rosabel M Bencomo MD PA / MDteleMe and any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf.
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. If it does include this information, I specifically authorize release of that information to the person(s) listed above.
INFORMATION TO BE DISCLOSED:*

General Medical Record(s), including TB progress notes consultations.History and Physical Results, Immunizations, Family Planning, Prenatal Records.Diagnostic Test ReportsOther
PURPOSE OF DISCLOSURE:*

Treatment PersonalUse Billing/PaymentContinuity of CareOther
EXPIRATION DATE: This authorization will expire (insert date or event):
(Insert date or event) I understand that if I fail to specify an expiration date or event, this authorization will expire twelve (12) months from the date on which it was signed.
REDISCLOSURE: I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.
CONDITIONING: I understand that completing this authorization form is voluntary and that treatment, payment, enrollment, or eligibility for benefits cannot be conditioned on whether I sign this authorization.
REVOCATION: I understand that I have the right to revoke this authorization any time. If I revoke this authorization, I understand that I must do so in writing and that I must present my revocation to the medical record department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company, Medicaid and Medicare.
I request and authorize the disclosure of information described above.
Signature - Certification of Authorization
Should be Empty: