Advanced Urology Institute | Urologists in Florida, USA
Advanced Urology Institute RAMOS, HEALEY, BEISWANGER, EISENBROWN, JENKINS, HITT, JAMES WILKINS, PA-C,80 Doctors Drive – Panama City, FL. 32405 – Phone 850-785-8557 – Fax 850-785-1123625 W. Baldwin Road, Suite 1 – Panama City, FL. 32405Authorization for Release of Medical RecordsPatient: ________________________________________ DOB: _______________________________Phone: ________________________________________ Acct #: ______________________________By signing this authorization, I authorize Advance Urology Institute to use, receive, or disclose certain (PHI) Protected Health Information about myself.Release Records To:Primary Doctor: ______________________________________Phone/Fax:______________________________Oncologist: __________________________________________Phone/Fax:______________________________Radiologist: __________________________________________Phone/Fax:______________________________ Other: ______________________________________________Phone/Fax:______________________________Please have my physician send the following information. (Mark all that apply)Complete Record Radiology (CT,US, X-ray)PET CTLabsOperative notesPathology / BiopsyPurpose of Disclosure: Further Medical Treatment This release will expire one (1) year from the signed date. I understand that I have the right to revoke this authorization at any time by providing written notice to this practice. Call patient to pick up records.Mail to patient or other. Address: ____________________________________________________________________________________________________ __________________________________________Signature of patient or legal guardian Date Signed__________________________________________ ___________________________________________Patient Name or legal guardian (Please Print) Relationship to the patient ---------------------------------------------------For Office Use---------------------------------------------------------------------Date requested: ______________________ Date released: ______________________________Date Copied: ________________________ Employee: __________________________________ ................
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