Full Medical Records Release Form printable pdf download

UNIVERSAL PATIENT AUTHORIZATION FORM FOR

FULL DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT AND QUALITY OF CARE

***PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW***

Patient (name and information of person whose health information is being disclosed):

Name (First Middle Last):

Date of Birth (mm/dd/yyyy):

Address:

City:

State:

Zip:

You may use this form to allow your healthcare provider to access and use your health information. Your

choice on whether to sign this form will not affect your ability to get medical treatment, payment for

medical treatment, or health insurance enrollment or eligibility for benefits.

By signing this form, I voluntarily authorize, give my permission and allow use and disclosure:

OF WHAT: ALL MY HEALTH INFORMATION including any information about sensitive conditions (if any) [See page 2 for details]

FROM WHOM: ALL information sources [See page 2 for details]

TO WHOM: Specific person(s) or organization(s) permitted to receive my information (must be a healthcare provider):

Person/Organization Name:

Phone: ( )

Address:

Fax: ( )

PURPOSE: To provide me with medical treatment and related services and products, and to evaluate and improve patient safety and

the quality of medical care provided to all patients.

EFFECTIVE PERIOD: This authorization/permission form will remain in effect until my death or the day I withdraw my permission.

REVOKING MY PERMISSION: I can revoke my permission at any time by giving written notice to the person or organization named

above in “To Whom.”

In addition:



I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.



I understand that there are some circumstances in which this information may be redisclosed to other persons [See page 2 for

details].



I understand that refusing to sign this form does not stop disclosure of my health information that is otherwise permitted by

law without my specific authorization or permission.



I have read all pages of this form and agree to the disclosures above from the types of sources listed.

_____

Signature of Patient or Patient’s Legal Representative

Date Signed (mm/dd/yyyy)

_____

Print Name of Legal Representative (if applicable)

Check one to describe the relationship of Legal Representative to Patient (if applicable):

 Parent of minor

 Guardian

 Other personal representative (explain:

)

NOTE: This form is invalid if modified. You are entitled to get a copy of this form after you sign it.

Form Florida AHCA FC4200-004 (July 1, 2011)

59B-16.002, F.A.C.

Page 1 of 2

Full Medical Records Release Form

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