Download pdf - Patient Name: Date of Birth: Phone Number: Last Four of SS ... · Patient Name: _____ Date of Birth: _____ Address: _____ City: _____ Zip: _____

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Page 1: Patient Name: Date of Birth: Phone Number: Last Four of SS ... · Patient Name: _____ Date of Birth: _____ Address: _____ City: _____ Zip: _____

Patient Name: _____________________________ Date of Birth: ______________________

Address: _________________________________ City: ________________ Zip: _________

Phone Number: ____________________________ Last Four of SS# Only: ______________

Please send the requested information below:

Entire Medical Record: ____ Office Notes: _____ Test Results: ____ Radiology Reports: ____

Referrals: _____ Consults: ______

Reason for the request: Transfer of Care: _____ Healthcare: _____ Personal: _______

I authorize Orange Blossom Women’s Group to obtain records from: Provider Name: _____________________________

Address: __________________________________

City, State, Zip: _____________________________

Phone number: _____________________________

Fax number: _______________________________

I authorize Orange Blossom Women’s Group to send records to: Provider Name: _____________________________

Address: __________________________________

City, State, Zip: _____________________________

Phone number: _____________________________

Fax number: _______________________________

I understand and agree that health information about me, which is used or disclosed pursuant to this

authorization, may be subject to re-disclosure by the recipient and may no longer be protected by law.

This authorization is valid for 12 months following the date of my signature shown below. I have the right to

revoke this authorization in writing at any time. I acknowledge that such a revocation is not effective to the

extent the above person/organization has relied on the use or disclosure of my health information.

I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my signature

below. I am entitled to a copy of this authorization.

Signature:____________________________ Date: ____________________________

________________________________________________________________________________________

Office Use Only

Received Date:_______________________ Date Faxed: ________________________

Orange Blossom Women’s Group 2043 Little Road Trinity, Fl 34655

Phone (727) 846 - 7000 Fax: (877) 260-1182

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