Florida Medical Records Release Form 1
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13330 USF Laurel Drive, MDC 33
Phone (813) 974-9818
Fax (813) 974-4280

Authorization to Records Custodian
for the Release of Medical Records
Patientís Name

Date of birth

Patientís last 4 Number of Social Security No.

Medical Record No.

Representative Name

Relationship to Patient

Representative Address

Legal Authority

Verification of Identity

Verfication of Authority

By signing this form I understand that I am authorizing the designated medical records custodians or database custodian to use and/or disclose my protected health
information (PHI) as defined under 45 CFR 164.501, the federal regulations implementing the Health Insurance Portability and Accountability Act of 1996 (ìHIPAAî) as
described below to the following person(s) or organization(s)
Release to: ____________________________________________

Obtain from: ____________________________________________________

_____________________________________________________
Name

_____________________________________________