Request for Access to PHI

Patient Information

First Name

MI

Last Name

Date of Birth

Email

Phone

Mailing Address

Authorization to release my medical records

I authorize

to disclose to

Self

or to

Named person or entity

A fee for medical record copies may apply. A patient whose records are copied and sent to another healthcare provider for the purpose of continuing to receive medical care does not pay a fee for medical record copies. Requests for medical record copies for any use other than medical care will be billed as follows:
Fees for medical records will be charged in accordance with applicable State and Federal regulation:
F.S.395.3025 - Fees for medical record copies related to Health facilities and ambulatory surgery
F.S.456.057 - Fees for medical record copies related to Healthcare practitioners and physicians' offices
45 CFR(164.524)(c)(4) - Fees for electronic copy of records.

Recipient Name

Recipient E-mail :

Recipient Phone

Recipient Fax

Mailing Address

Information to Release

What to Release (check all that apply)

Resumen de expedientes médicos i

Cirugía ambulatoria i

Informes de cardiología i

Informes de consultas i

COVID-19 Report i

Resumen de alta i

Expediente del Departamento de Emergencias (ED) i

Ingreso en el hospital i

Antecedentes y examen físico i

Resultados de pruebas de laboratorio i

Informes quirúrgicos i

Expediente de paciente ambulatorio/consultorio del médico únicamente i

Informes de patología i

Notas del consultorio del médico i

Informes de radiología i

From Date i

To Date i

Disclosure of sensitive information

You have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions, treatments, or testing listed below. Please note only the items you check below will be released and no information will be released without your explicit consent. Include (indicate by checking below):

Psychological/Psychiatric conditions i

Drug and/or alcohol abuse diagnosis and/or treatment i

HIV AIDS diagnosis and/or treatment i

Genetic Testing i

I authorize the disclosure of ALL sensitive information

I DO NOT authorize the disclosure of ANY sensitive information

* If you select the option to not release any sensitive information, your records will have all sensitive information redacted. Please note that the information will not be released if you do not check at least one box.

Delivery Method

Released By

Email i

Mail Paper Records i

Dates of service

Consent Expiration Date i

Review & Submit for Signature

Cancel my request for records

Authorization for Release of Medical Information Autorización para Divulgar Expedientes Médicos

Patient InformationInformación del paciente

Authorization to release my medical records AUTORIZACIÓN PARA DIVULGAR MIS EXPEDIENTES MÉDICOS

Information to Release INFORMACIÓN QUE SE DIVULGARÁ

Disclosure of sensitive information Revelación de información sensible

Delivery Method Método de entrega

Authorization for Release of Medical Information

Patient Information

Authorization to release my medical records

Information to Release

Disclosure of sensitive information

Delivery Method