|
PATIENT: ______________________________________________________________ DOB: ________________________________ SSN: ____________________________ NOTE TO RECEIVING PARTY: This information is disclosed to you from records whose confidentiality is protected by law. Any redisclosure is strictly prohibited without the written permission of the patient/client/legal representative identified below: I authorize
______________________________________________________________ ______________________________________________________________ to release from my medical record, general medical information (FL Statute 395.017) as well as psychiatric/psychological information, alcohol and/or drug abuse information (FL Statute 394.459 and Fed. Reg. 42CFA, Part II), Human Immunodeficiency Virus (HIV) tests and other information pertaining to these tests or to treatment in connection with these test results to:
______________________________________________________________ ______________________________________________________________
_________________________________________ _______________________ PATIENT SIGNATURE DATE
________________________________________
I understand that I have the right to refuse or to withdraw this authorization (withdrawal must be in writing). I also understand that this authorization will remain in effect indefinitely unless I specify an earlier expiration date here: _________________(date).
_____________________ ____________________________________ DATE REVOKED PATIENT SIGNATURE |