Patient Information

Release Information To

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

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))

Authorization to Release Protected Health 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.
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.

Contact Us

Main Office:
2330 South Congress Avenue
Palm Springs, FL 33406

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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.