• Celebration Obstetrics & Gynecology Associates, P.A.

     410 Celebration Place, Suite 208, Celebration, Florida 34747

    2209 North Boulevard, Suite C, Davenport, Florida 33837 Phone:

    407-566-2229 Fax: 407-566-2499

     

    AUTHORIZATION TO REQUEST OR RELEASE HEALTH INFORMATION

  • , hereby authorize Celebration Obstetrics and Gynecology to:

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  • By indicating “Entire Record” all medical information, information regarding any sexually transmitted disease, psychiatric treatment, drug and/or alcohol abuse, HIV testing, ARC and/or AIDS information in my records will be released. If you prefer certain medical information not be released, please contact the appropriate office staff.

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  • Fee for copying chart: $1.00 up to 25 pages, .25 cents per page thereafter. Authorization must be signed and payment received before chart will be copied. Please allow 7 to 10 working days to copy chart.

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