Authorization For The Miami Medical Center To Release Medical Information Form printable pdf download

AUTHORIZATION FOR THE MIAMI MEDICAL CENTER TO RELEASE MEDICAL INFORMATION

Please print information to ensure legibility. Medical record copies required for continuation of care are provided free of charge. Other copies of

records required will be charged a fee according to FL State Laws (Statute 395.3025). Authorization dates on this release form must be subsequent

to dates of care. A copy of this authorization will be considered as valid as the original. Patients may revoke this authorization at any time in

writing before the expiration date, except to the extent that action has already been taken by The Miami Medical Center to fulfill this authorization.

Patient Name: _____________________________________________________________Date of Birth: _______________________

Address: ____________________________________________________________________________________________________

Name and Address of Individual or Facility to whom disclosure is to be made:

Name: ______________________________________________________________________________________________________

Address:___________________________________________City:___________________________State:_______Zip Code:________

Select by indicating with a check mark the information to be disclosed, reason needed, and the media type preferred.

Records requested for: _____Continued Patient Care _____3

Party Payer _____Personal

____Other Reasons

Media type requested: ____Hard Copy/Paper _____Computer Disc (CD) ____Fax (Number: (______- _______________))

Date(s) of Episode of Care: ____________________________________________Records Requested (Check all that apply below):

Face Sheet

History &

Operative Report

Medications

Progress Notes

Physical

Discharge

Immunizations

Consultations

Physician Orders

Summary

Instructions

Lab Reports

Pathology

Radiology Reports

Echo Reports

EKG Reports

Reports

EEG Reports

Sleep Study

Pulmonary

Therapy Records:

Entire Medical Record

Function Test

Physical, Speech,

Occupational,

Other:

Additional signature and initials are required in this section due to the sensitivity of these records. Check records below that are to be included in

your request. Initial, sign, and date in this section indicating that you are authorizing the release of sensitive records.

__Drug Substance Records __Behavioral/Psychiatry ___Lab Sensitive (HIV/STD/Drug Screen/Pregnancy)

Initials: _____ Signature:___________________________________________________________ Date:_________________

This authorization must be signed and dated by the patient. In lieu of a patient signature, a parent, legal guardian or legal representative must sign

and have the signature witnessed. This consent is subject to revocation at any time except when fulfillment of the request has already occurred.

This consent automatically expires 90 days from the date of requestor’s signature.

Patient Signature: _____________________________________________ Phone:_____________________ Date:________________

Parent/Guardian/Legal Representative: Signature: ____________________________________________________Phone:_________

Mailing Address or Fax Number: _____________________________________________________________________________________

________________________________________________________________________________________________________________

Relationship (Please check): _____ Parent _____Guardian _____ Legal Representative Date: _____________________

Witness Signature: _________________________________________________________________ Date: _____________________

Authorization For The Miami Medical Center To Release Medical Information Form

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