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)
   
Under Florida Statute Section 456.057 (7) records may be released without a signed authorization to health care practitioners and providers involved in the care or treatment of the patient.

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.