Request For Access And Authorization For Use And/or Disclosure Of Protected Health Information


Request for Access and Authorization for Use and/or Disclosure of Protected Health Information
Please allow a minimum of two business days to process your request.
I understand that the protected health information specified below may include mental health, substance abuse (e.g., drugs, alcohol) HIV/AIDS status
information, diagnostic and treatment records.
I have read and understand the following statements:
I may revoke this authorization at any time by notifying the Health Information Management department in writing.
I understand that my revocation does not affect any disclosure made prior to the revocation being received and processed.
I understand the information disclosed may be subject to redisclosure and no longer be protected by federal or state privacy laws.
I understand that I am signing this form voluntarily and I am signing this under my own free will. Florida Hospital will not condition my
treatment, payment enrollment in health plans or my eligibility for benefits by signing this form.
I understand that I will receive a signed copy of this form.
I further agree to pay charges to provide the information request per Florida Statute 395.3025.
I understand that unless otherwise revoked, this authorization will expire upon the following date, event or condition: ________________.
If no expiration date, event or condition is noted this authorization will expire 1 year from the date signed.
I am the patient and I understand and agree to the provisions of this form/authorization
I understand and agree to the provisions of this form on behalf of the individual indicated below to be the patient. I have signed my name
individually as the representative of the patient and have attached a copy of the court order designating me as the guardian of the patient, or
documentation designating me as the Legally Authorized Person (LAP) of the patient.
Patient’s Legal Name: ________________________________________________
MRN: _____________________________
Address: __________________________________________________________
Date of Birth: _______________________
Last 4 of SSN: _______________________
Patient Phone Number: ______________________________________________
I authorize Florida Hospital to:
Disclose to
Obtain from ______________________________
and send to below requestor
Name: _______________________________________________ Address: __________________________________________________
City: _________________________________
State: _________ Zip: _____________
Phone: _______________________________
Fax: _______________________
Electronic (please contact Health Information Management for details)
I understand that all records will be mailed unless specified.
Pick Up at ____________________ Hospital
The purpose of this request:
Personal Request
Treatment (Continued Care)
Other: ___________________________________________
Please furnish the following information specified below for the following Visit Dates: _________________________Check appropriate boxes below
Abstract of Record (Dictated Reports, laboratory, cardiology, radiology)
Emergency Department Records
Discharge Summary
Operative Report(s)
History & Physical
Laboratory Reports
Billing Records
Pathology Reports
Radiology Report(s)
Complete chart
Other: ______________________________
Patient Signature: _____________________________________________
Printed Patient Name:_____________________________________
Legally Authorized Person Signature: _____________________________
Print Name:_____________________________________________
Witness Signature: ____________________________________________
Print Name:_____________________________________________
Date :______________________________
Request for Access has been:
Partially Denied
If access is denied and patient requests review of denial, contact the Release of Information office below.
Medical Records released/accessed: Date of release/Access______________________
Release of Information Contact Information Mailing Address only:
Florida Hospital Health Information Management
Release of Information
701 E. Altamonte Dr, Suite 2000
Altamonte Springs, FL 32701
Phone: 407-303-9175 Fax: 407-303-0633
You have the right to complain to the Office of Civil Rights. The following is the contact information:
Office of Civil Rights ~ U S Department of Health & Human Services 61 Forsyth Street, SW. Suite 3B70 Atlanta, GA 30323 ~ Phone# 404-562-7886; 404-331-2867 ~ Fax# 404-562-7881
Patient Name__________________________
Request for Access and Authorization for Use and/or Disclosure of Protected Health Information
FIN_____________ MRN_______________
Tab: Legal Forms & Consents
DH: Release of Information
768-0600 (12/11) MPC 765
or Patient Label


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