• Authorization to Disclose Protected Health Information

    This form is for all record requests.
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    Covering the following period(s) of health care:

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  • If I fail to specify an expiration date, event, or condition, this authorization will expire in 90 days. If this authorization pertains to oneself as the patient, the expiration date can be documented as unlimited. If documented as such, it is the responsibility of the individual to notify the practice of any life changes, i.e. guardianship, so that appropriate documentation is given for the change.

    I understand that any disclosure of healthcare information carries with it the potential for unauthorized and future re-disclosures, as allowed by HIPAA and other federal privacy rules.  If I have questions about disclosures of my health information, I can contact my provider of care.

    This facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

    Fees for copies of medical records in paper or electronic onto disk to be charged in accordance with the State of Florida fee schedule and the actual cost of postage. 

    PATIENT NAME: {patientName}

    NAME OF PATIENT'S LEGAL REPRESENTATIVE: {nameOf}

    DATE: {date343}

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