Florida Medical Records Release Form 3
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Florida State University
University Health Services
Health Information Management
960 Learning Way
P.O. Box 3064178
Tallahassee, FL 32306-4178
(850) 644-5523, Fax: (850) 644-2737

OFFICE USE ONLY
UHS ID #
___________
ID CHECKED__________
COMPLETED__________
EMPLOYEE ___________

FAX ___________
MAIL __________
PICK UP________
PAID ___________

Authorization for the Use, Disclosure and Receipt of Protected Health Information
I request and authorize:

To release my medical information to:

___________________________________

______________________________________

___________________________________

______________________________________

___________________________________

______________________________________

Specific Medical Records Requested – PLEASE INDICATE DATES OF SERVICE_____/_____/_____ to _____/_____/_____.
(Note: Only the most recent edition/form will be sent unless dates of service are specified):

Please check the boxes adjacent to the items for which you are requestin