The Garramone Center
Charles E. Garramone, D.O.
Plastic & Reconstructive Surgery
4725 SW148th Ave, Suite 202,
Davie, FL 33330
If you want to allow us to speak with anyone else regarding your appointments, financial payments,
scheduling, protected health information, etc, you must fill out this form completely and fax it to
(954) 473-2454 or email to
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS/PROTECTED HEALTH INFORMATIONThis
document must be signed by the patient or person authorized by law.
City: _______________ State: __________
Zip Code: _________________
Date of Birth:
Social Security Number:
Other identifying information if applicable (other names):
Transmission by facsimile (fax) or electronic means (email) is authorized by the signed patient to expedite transfer
I, ____________________________, hereby authorize Aesthetic Plastic Surgery Institute, PA and its
associates to discuss, release, or obtain the records identified on Exhibit A to this Authorization for Release of
Protected Health Information. I agree to be responsible for all photocopying charges associated with the
reproduction of such records.
This Authorization for Release of Protected Health Information applies only to the release of the records
identified on Exhibit A. Such records should be released or obtained from or to
[name and address of recipient] for the following purpose(s):
I understand that providing my authorization is voluntary. I need not sign this Authorization for Release of
Protected Health Information to continue to receive healthcare treatment Aesthetic Plastic Surgery Institute, PA
and its associates . I understand that I may revoke this authorization, in writing, at any time except to the extent
that disclosure was made prior to the time I revoked this authorization. I further understand that I may inspect and
receive copies of the information to be disclosed.
I understand that the health records and information disclosed, or some portion thereof, may be protected
by the Federal Health Insurance Portability and Accountability Act (“HIPAA”). I further understand that it is
possible that the information described above may be re-disclosed by the recipient and may no longer be
protected by HIPAA, and that all means of voice, fax, or email transmission may be unencrypted or not secure,
and Aesthetic Plastic Surgery Institute, PA and its associates are not responsible for unauthorized access
of protected health information while in transmission to the individual based on the individual's request.
Further, Aesthetic Plastic Surgery Institute, PA and its associates are not responsible for safeguarding
information once delivered to the individual. I further understand that my records may be protected under
state law and, if so, cannot be disclosed without my written consent unless otherwise provided for in the law
My signature below acknowledges that I have read, understand, and authorize the release of the
information described on Exhibit A.
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