Authorization To Receive and Access And Use Health Information

Authorization To Receive/Access And Use Health Information

Patient First Name *

Patient Middle Name

Patient Last Name *

Date of Birth *

Patient Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Phone *

Patient Social Security No. *

I Request and Authorize the following Facility/Organization/Person to release the health information of the patient named above to:

Celebration Family Physicians

1530 Celebration Boulevard Suite 103 Celebration, FL 34747
Fax Number 1-877-553-1366
Phone Number 407-566-8898

Name of Facility / Organization / Person *

Address of Facility / Organization / Person *

Address Line 1

Address Line 2

City

State

Zip Code

Phone of Facility / Organization / Person *

Fax Number of Facility / Organization / Person *

PLEASE FAX (preferred) OR MAIL THE HEALTH INFORMATION INDICATED BELOW:

Please Select date(s) of services (s):

From

To

Select Records / Results

Other

Request & Authorization

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s)/entity listed above. I must give permission before disclosure of these results.
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s)/entity listed above.

PURPOSE OF RELEASE

Other

Printed Name of Patient or Legal Representative *

Relationship to Patient *

Signature of Patient or Legal Representative *

Date of Signature *

This authorization expires 1 year from the date it is signed.
The information contained in this facsimile is privileged and confidential and is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this information is strictly prohibited. If you have received this information in error, please call us immediately and destroy the copy in your possession or return the entire transmittal to the address on this form via the U.S. Postal Service