13330 USF Laurel Drive, MDC 33
Phone (813) 974-9818
Fax (813) 974-4280
Authorization to Records Custodian
for the Release of Medical Records
Date of birth
Patientís last 4 Number of Social Security No.
Medical Record No.
Relationship to Patient
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: ____________________________________________________