Quick Primary Care

Medical Records Release - Page 9 of 9


Records to be released from: ( Physician or Company )

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 HWY 200, Ocala, FL 34481

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 any time, except to the extent information has been released in reliance to this authorization.
  • The information released I response to this may be re-disclosed to other parties.
  • My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.