Form Dh 3203 - Authorization To Disclosure Confidential Information - Florida Department Of Health
ADVERTISEMENT
1AUTHORIZATION TO DISCLOSE
CONFIDENTIAL INFORMATION
INFORMATION MAY BE DISCLOSED BY:
Person/Facility: __________________________________________________
Phone #: ________________________
Address: _______________________________________________________
Fax #: __________________________
INFORMATION MAY BE DISCLOSED TO:
Person/Facility: __________________________________________________
Phone #: ________________________
Address: ________________________________________________________
Fax #: __________________________
Other method of communication: ___________________________________________________________________________
I specifically authorize release of information relating to: (initial selection)
☐ General Medical Record(s), including STD and TB
☐ Progress Notes
☐ History and Physical
Results
☐ Immunizations
☐ Family Planning
☐ Prenatal Records
☐ Consultations
☐ Diagnostic Test Reports (Specify Type of Test(s)_____________________________________________________________
☐ Other (Specify):_______________________________________________________________________________________
I specifically authorize release of information relating to: (initial selection)
☐ HIV test results for non-treatment purposes
☐ Substance Abuse Service Provider Client Records
☐ Psychiatric, Psychological or Psychotherapeutic notes
☐ Early Intervention
☐ WIC
PUROPSE OF DISCLOSURE:
☐ Continuity of Care
☐ Personal Use
☐ Other
(Specify):_________________________________________
EXPIRATION DATE: This authorization will expire (insert date or event)______________________________. I understand
that if I fail to specify an expiration date or event, this authorization will expire twelve (12) months from the date on which it
was signed.
REDISCLOSURE: I understand that once the above information is disclosed, it may be redisclosed by the recipient and the
information may not be protected by federal privacy laws or regulations.
CONDITIONING: I understand that completing this authorization form is voluntary. I realize that treatment will not be denied
if I refuse to sign this form.
REVOCATION: I understand that I have the right to revoke this authorization any time. If I revoke this authorization, I
understand that I must do so in writing and that I must present my revocation to the medical record department. I understand
that the revocation will not apply to information that has already been released in response to this authorization. I understand
that the revocation will not apply to my insurance company, Medicaid and Medicare.
________________________________________________
________________________________________
Client/Representative Signature
Date
________________________________________________
________________________________________
Printed Name
Representative’s Relationship to Client
________________________________________________
________________________________________
Witness (optional)
Date
Client Name: ____________________________
ID#:
________________________________
DOB:
________________________________
DH 3203
Original: To File Copy: To Client Copy: To Accompany Disclosure
Revised May 2015
CONFIDENTIAL
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Prob 11e - Authorization To Release Confidential Information Substance Abuse And Mental Health Treatment Programs - U.s. Probation System
Legal
Form Prob 11i - Authorization To Release Confidential Information Mental Health Treatment Programs - Us Probation System
Legal
Dh Form 673 - Certified Statement Of Final Judgment Of Paternity - Florida Department Of Health
Legal
Form Dh-1622 - Occupational Exposure Record For A Monitoring Period - Florida Department Of Health
Legal
Related Categories
Parent category: Legal