Medical Request Online Form

Patient Information

Patient Full Name *

Other Names? *

Patient Address *

Date of Birth *

City *

State *

Zip *

Phone *

Release Information To

Email address for record delivery *

Name/Facility *

Attention

Address *

Phone *

City *

State *

Zip *

Fax

Purpose of Request *

Personal

Treatment

Legal

Insurance

Transfer

Other

Information to be Released | If you fail to specify, a 1-year abstract will be provided.

Please release a 1-year abstract of my records (includes most recent notes, labs, procedures& testing)

Please release a 2-year abstract of my records (officenotes,labs,procedures & testing, up to 2 years)

Please pick ONE delivery option *

Send by Email

Fax to Doctor

Records on Paper

Records on CD

Pursuant to HIPAA45CFR,164.524,we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies.If you want the entire medical record, the rate will increase proportionally based on the cost.At no time will the cost-based fees exceed Florida Statute: (395.3025(1))

Date Range *

Other

Progress Notes

Radiology Reports

Labs

Operative Reports

Injections

Physical Therapy

Authorization to Release Protected Health Information

I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information. *

I understand that: I may refuse to sign this authorization and that it is strictly voluntary. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation.

Unless otherwise revoked, this authorization will expire on the following date, event or condition:

If I do not specify expiration this authorization will expire in 90 days. If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by Federal Privacy Regulations and may be disclosed. I understand that I may see and obtain a copy of the information described on this form frir a reasonable copy fee, if I ask for it. I can request a copy of this form after I sign and date it.

Please confirm that you have filled out this form in its entirety—if form is incomplete, or if protected information is not released, we may be unable to fulfill this request.

Signature *

Date *

reCAPTCHA *

Name

Contact Us

Main Office:
2330 South Congress Avenue
Palm Springs, FL 33406
561-432-5849

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Compliance

Phone:561-432-7903
Notice of Privacy Practices

Award & Identity

This health center is a Health Center Program grantee under 42 U.S.C. 254b. This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.