Authorization to Disclose Protected Health Information

Authorization to Disclose Protected Health Information

This form is for all record requests.
Today's Date

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Is the Patient a minor under the age of 18?*
Name of Guardian or Legally Authorized Representative*

First NameLast Name
Guardian or Legal Representative Relationship to Patient*
Patient Phone Number*

Area CodePhone Number
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please select the appropriate option:*

TO DISCLOSE: I am requesting medical records from Dr. Fabio Echavarria, M.D., PATO OBTAIN: I am requesting medical records be sent to Dr. Fabio Echavarria, M.D., PA
The Records are being Sent to / Requested From: *
Insert Healthcare Provider Name, Address & Phone or ‘Self’
Covering the following period(s) of health care:
From:*

MonthDayYear
Date
To:*

MonthDayYear
Date
Information for disclosure, if included in my records:*

Complete Health RecordVisit SummaryHistory & PhysicalConsultation ReportsProgress NotesProcedure ReportsAnesthesia RecordDiagnostic ImagingPhotographs, Videos, Digital or Other Images
Laboratory tests for disclosure*
Please specify
If applicable, I also give permission for the following to be disclosed

Acquired Immunodeficiency Syndrome (AIDS) or Infection with Human Immunodeficiency Virus (HIV)Behavioral Health Services / Psychiatric Care /Mental HealthSexually Transmitted Diseases (STD)Treatment for Alcohol and/or Drug abusePt under age 18 y/o- Pregnancy information
Why do you need these records?*
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the provider(s) of care. 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 when the law provides my insurer with the right to review or contest a claim. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: *
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}
Signature of Patient or Patient's Legal Representative*

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