Asps Authorization To Release Medical Records Page 2
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1
2The Garramone Center
Charles E. Garramone, D.O.
Plastic & Reconstructive Surgery
4725 SW148th Ave, Suite 202,
Davie, FL 33330
954-752-7842
EXHIBIT A
DESCRIPTION OF HEALTH INFORMATION
SUBJECT TO AUTHORIZATION
By placing a check-mark in the spaces below, I,____________________________ , authorize the
release of the following records pertaining to services from
all dates
to
[insert dates]:
___
Complete medical record (all information)
___
All hospital/institution records (includes nursing records/progress notes)
___
Transcribed hospital/institution records (includes surgical reports, history/physical exam,
consultation reports, discharge summary reports)
___
Laboratory reports
___
Pathology reports
___
Diagnostic imaging reports
___
EKG/cardiac reports
___
Physical/occupational therapy reports
___
Billing statements
___
Physician office/clinical records
___
Implant information (including operative report)
___
Photographs
Release of the following information may be governed by additional laws. I understand and agree that
this information will be disclosed only if I place my initials in the applicable space next to the type of information:
___
HIV/AIDS information
___
Mental health information
___
Genetic testing information
___
Drug/alcohol diagnosis, treatment, or referral information
Date:
[Name]
Page 2 of 2
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