Florida Authorization To Disclose Health InformationFlorida Authorization To Disclose Health Information
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Health Information Management Dept.
P.O. Box 1289
Tampa, FL 33601-1289
Phone: (813) 844-7533

Authorization To Disclose Health Information
Patient Name
Last

First

Middle Initial

Street Address

Apt
State

City

Zip

Birth date

Work Phone

Home Phone

Age

SSN

The undersigned hereby authorizes and requests Tampa General Hospital to provide to:

Identity of Third Party or Authorized Representative / Name of Health Care Facility
Street Address

Suite/Floor
State

City

Zip

Phone

Per Florida Statues, hospitals are authorized to charge a $1.00 per page for copies of medical records.
Check the box next to each type of information to be disclosed (include dates where indicated):
 Most recent history and physical or specific date(s)
 Most recent discharge summary or specific date(s)
 Consultation reports, specify date(s)
 Laboratory results, specify types or dates
 Other diagnostic testing results, specify types or dates
 Entire record, specify date
 Abstract, specify date ( incl