IMIZ01 Medical Release Form

Release of Medical Information

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Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Permission to obtain records:
I, the above named patient with the above date of birth, voluntarily consent to an authorize my health care provider and or hospital (see name below) to use or disclose my health information during the term of this Authorization to the recipient(s) so that he/she can better understand my condition and help me.

Miguel Rodriguez MDRamon Leon MD
Name of hospital (if applicable)
Requesting records from:
Name of Practice
Name of Physician
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records within the following dates

Any and all types of records for this patient including mental health, HIV/AIDS results, and substance abuse.Records between the dates of -
I understand that:
- I do not have to give permission to share these records.
- If I want to take away the permission for my doctor to get these records, I need to talk to my doctor or a staff person and sign a paper.
Please send records to:
Attention:
At fax number:           305-503-9236

With phone number: 786-310-7477

Or mail to: 9380 SW 150th St., Suite 140

Miami, FL 33176
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Patient Or Authorized Representative Signature*

Clear
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty: