By signing and dating below I,

 

 

Whose date of birth is,

 

 

ALL MEDICAL RECORDS INCLUDING ASSESSMENT, DIAGNOSIS, PSYCHIATRIC EVALUATION, TREATMENT PLANS, AND MEDICATION MANAGEMENT AS STAFF DEEMS APPROPRIATE.

 

REVOCATION:
 

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to John W. Grace, M.D., P.A. at 6226 West Corporate Oaks Drive, Crystal River, Florida 34429.   

 

Expiration:

 

Unless sooner revoked, this authorization expires three years from the date of this signature. 

 

Form of Disclosure:

 

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, in paper format or electronically.

NOTE:  THIS FORM IS ONLY ACCEPTABLE IF THE NAME ON THE CREDIT CARD FOR PAYMENT MATCHES THE REQUESTOR OF RECORDS.  PAYMENT MUST BE AT LEAST $1.00 TO REGISTER.  YOU MAY ALSO WANT TO CONTACT THE OFFICE FIRST TO INQUIRE ABOUT THE COST OF RELEASE OF RECORDS WHICH IN LARGE FILES MAY BE CONSIDERABLE OR WITH OTHER QUESTIONS.