Authorization for Release of Medical Information

For use by a parent, or legal guardian, requesting medical records of a patient

Patient Information
Personal Representative
Supporting Documentation
Authorization to release my medical records
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.
Information to Release
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. To exclude this information from disclosure, check the appropriate checkbox(es). To EXCLUDE this information with disclosure, check the last checkbox in the list.

Delivery Method