Please read and sign the form below. Once you click submit, you will automatically be presented with the next form. Authorization for Release of Medical Records Patient Full Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Name First Last PhoneEmail Physician Name*Physician Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician Fax Number*for the sole purpose of medical records review and certification of my medical condition. I understand the information to be release or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information. This authorization is intended to be an unlimited, full, and complete Authorization for the release of any and all protected medical information as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Medical Records Access Act, as amended, and under the rules and regulations thereof, and covers all protected information from primary and secondary providers, health plans, health care clearinghouses, emergency services, financial and administrative transactions, and business associates. A covered entity not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization when the prohibition on conditioning of authorizations in 45 CFR 164.508(b) (4) applies. It is understood that the person to whom this Authorization is given has my permission to use and disseminate this information in his or her sole discretion. Expiration. This authorization expires 24 months after patient signed this release. Right to Revoke. I have the right to this authorization by signing and dating a written statement revoking this authorization, and it shall become effective on delivery to you. If this authorization is revoked, any person or entity acting in good faith in reliance upon it and lacking actual knowledge of its revocation shall be held harmless. Redisclosure. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected by this rule. Administrative Provisions. I revoke any prior authorizations I have made to disclose health information that are inconsistent with this authorization. This document shall be governed by Florida law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub L No 104-191, and the Medical Records Access Act, MCL 333.26261etseq. However, I intend it to be honored in any jurisdiction where it is presented and for other jurisdictions to refer to Florida law and HIPAA to interpret and determine the validity and enforceability of this document. Photocopies or facsimile reproductions of this signed authorization shall be treated as original counterparts. I an providing this authorization voluntarily and have not been required to give it to obtain treatment. I am at lease 18 years old and of sound mind. Any Billing for Medical Records is solely the patient's responsibility.Digital Signature*By typing your full legal name, this serves as your legal signature and that you acknowledge you have read and agree with or will comply with the terms of the document you are signing under penalty of perjury.