AUTHORIZATION TO RELEASE/OBTAIN INFORMATION

There is a charge for copying your records, due at time of service or before records will be mailed or faxed. The charge is $1.00 per page for the first 25 pages and $0.25 per page there after. Please make checks payable to Orlando Heart Center. Records sent to another treating Physician will be faxed at no charge.

Patient Name: 
Date of Birth:   Social Security #: 
The above named patient authorizes Orlando Heart Center to:

Obtain Information from:  Release Information to:

Name:
Address:
 
Phone: Fax:  

the following information that may contain information related to HIV/AIDS, sexually transmitted diseases, mental health (excluding psychotherapy notes – a separate authorization is required), alcohol or substance abuse and genetic testing unless otherwise restricted by me.

Office Notes Non-Invasive Tests
H/P or Consultation Invasive Tests
Labs Operative Report
EKG DC Summary
CXR Report Other:  

By signing this authorization form, I authorize the use and disclosure of my health information. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment, or eligibility for health care benefits. I have signed this form voluntarily in order to document my wishes regarding the use and disclosure of my health information. I understand that I may revoke this authorization at any time, provided I do so in writing. I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed.

This authorization will expire 365 days from the date of signing.

A photocopy or fax of this authorization is as valid as this original.

_____________________________________________ _______________
Signature of Patient or Personal Representative Date
_____________________________________________
Personal Representative’s Authority (if applicable)  

Please Print and SIGN form before submiting.

OHC DOWNTOWN
60 West Gore Street
Orlando, Florida 32806
407-650-1300 · 407-650-1307		 OHC SANDLAKE
7236 Stonerock Circle
Orlando, Florida 32819
407-370-5800 · 407-370-5820		 OHC HEALTH CENTRAL
10000 W. Colonial Dr, #484
Ocoee, Florida 34761
407-290-3050 · 407-290-2118

At Orlando Heart Center we understand privacy is very important to our patients.
Please feel free to review our privacy policy at any time.