QPC New Patient - Page 9

Quick Primary Care

Medical Records Release - Page 9 of 9

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION

Records to be released from your PREVIOUS (Physician or Company) *

New Patient Info (Continued...)

Medical Records Release

Patient Information

Authorization

I authorize and request the disclosure of all protected information for the purpose of review and evaluation from the above-named doctor or healthcare provider to:

Requested information (if more than 25 pages, please mail): 8550 SW State Road 200, Ocala, FL 34481

Records to Include

Authorization

Authorization: I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. This authorization will automatically expire upon satisfaction of the need for disclosure or if revoked in writing by the patient. I understand that a copy of this authorization may be used with the same effectiveness as an original.

HIPAA REQUIRED STATEMENTS: I understand the following:
• I have a right to revoke this authorization in writing at

Signature

Legal Representative