AUTHORIZATION TO REQUEST or RELEASE HEALTH INFORMATION

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

I, *

Patient name

, hereby authorize Celebration Obstetrics and Gynecology to:

*

Request records from Release records to

Business Name: *

Phone: *

Physician Name: *

Fax: *

Address: *

The following type of medical information: (list dates and tests if specifics needed) *

YES

DETAILS

LAB RESULTS

IMAGE RESULTS

IMMUNIZATIONS

ENTIRE RECORD

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.

This information for which I am authorizing disclosure will be used for the following purpose: *

Second Opinion Relocation Transfer of Care Other

OTHER Reason Request:

If I fail to specify a date, this authorization will expire in 6 months from the date it was signed. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization in writing, the revocation will not apply to information that has already been released. 8. I understand that once the information has been disclosed, the recipient may re-disclose it and federal privacy laws may not protect the information.

Date

SIGNATURE *

Clear

DATE OF BIRTH *

Date

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.