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Florida Authorization To Disclose Health Information

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This form is provided by Tampa General Hospital to authorize the disclosure or release of one person's protected health information.

Florida Authorization To Disclose Health Information
Florida Authorization To Disclose Health Information
Form #: A-503 Rev. 09/17/10 FAQ’s on the reverse side
Health Information Management Dept.
P.O. Box 1289
Tampa, FL 33601-1289
Phone: (813) 844-7533
Authorization To Disclose Health Information
Patient Name
Last First Middle Initial
Street Address
Apt
City
State Zip Birth date Age
Home Phone Work Phone SSN
The undersigned hereby authorizes and requests Tampa General Hospital to provide to:
Identity of Third Party or Authorized Representative / Name of Health Care Facility
Street Address
Suite/Floor
City
State Zip Phone
Per Florida Statues, hospitals are authorized to charge a $1.00 per page for copies of medical records.
Check the box next to each type of information to be disclosed (include dates where indicated):
Most recent history and physical or specific date(s)
Most recent discharge summary or specific date(s)
Consultation reports, specify date(s)
Laboratory results, specify types or dates
Other diagnostic testing results, specify types or dates
Entire record, specify date
Abstract, specify date ( includes only pertinent treatment information)
Other, specify
Including HIV/AIDS testing, results, and/or treatment records
Including Mental Health treatment records, excluding psychotherapy notes
Including alcohol and/or drug abuse treatment records
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in
writing and present my written revocation to the health information management department or mail to the above address. I understand
that the revocation will not apply to information that has already been released in response to this authorization. I understand that any
disclosure of information carries with it the potential for re-disclosure and the information may not be protected by federal confidentiality
rules. If I have questions about the disclosure of health information, I can contact the Director of the Health Information Management
Department at (813) 844-7525.
Unless otherwise revoked, this authorization will expire on the following date, event or condition:
If I fail to specify an expiration date, event or condition, this authorization will expire in 90 days.
Signature of Patient or Legal Representative Signature of Witness
If signed by Legal Representative, Relationship to Patient Date
Florida Authorization To Disclose Health Information
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