Medical Release

Patient Authorization for Release of Health Records to External Parties

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY
  • I understand that I may withdraw or revoke my permission at any time. If I withdraw my permission, my information may no longer be used or released for the reasons covered by this authorization. However, any disclosures already made with my permission are unable to be taken back. I may revoke this authorization by notifying Florida Diabetes and Endocrine Associates LLC in writing.

    My treatment will not be based on the completion of this authorization form. The information to be released by this authorization may be re-released by the person or organization that receives it and may no longer be protected by Federal or Florida privacy regulations.

  • :
  • I release the individual or organization named in this authorization from legal responsibility or liability for the disclosure of the records as authorized on this form. I understand that this authorization is voluntary and that I may refuse to sign it. I will be provided a copy of this signed authorization, if requested. A photocopy of this authorization is as valid as the original.

  • Date Format: MM slash DD slash YYYY