AUTHORIZATION
TO
DISCLOSE
CONFIDENTIAL INFORMATION
INFORMATION
MAY
BE
DISCLOSED BY:
Person/Facility:
_____
_ _ _
___
_
__
_ _ _
___________
_
Phone#
:
---------
-
--
Address:
Fax#:
____________
_
INFORMATION
MAY BE DISCLOSED
TO
:
Person/Facility: _
____
_
__
___
_____
_
______
__
_
___
Phone#:-
-
--------
- -
Address:
Fax#:-------------
INFORMATION
TO
BE DISCLOSED: (Initial Selection)
__
General Medical Record(s), including STD and TB
Immunizations
__
Family Planning
__
Progress Notes
Prenatal Records
_ _ History and Physical Res
ul
ts
Consultations
__
Diagnostic Test Reports (SpecifY Type
ofte
s
t(
s)
------------------------
--
---
__
Other: (specifY)
----------
-----
------------
----
---
--
I specifically authorize release
of
information r
ela
ting to: (initial selection)
_ _ HIV test results for non-treatment purposes Substance Abu
se
Service Provider Client Records
_ _ Psychiatric, Psychological or Psychotherapeutic notes
__
Early Intervention
_ _ WIC
PURPOSE
OF
DISCLOSURE:
__
Continuity of Care
__
Personal Use
__
Other (specifY) _ _
__
_____
____
_ _
__
______
_ _
EXPIRATION DATE: This authorization
wi
ll
expire (insert date or event)
____
___
. I understand that
if
I fail to spec
ifY
an expiration
date or event, this authorization will expire twelve (12) months from the date on which it was signed.
REDISCLOSURE: I understand that once the above information is disclosed, it may be redisclosed by the recipient and
th
e information
ma
y not
be
protected by feder
al
privacy laws or regulation
s.
CONDITIONING: I understand that completing this authorization form is voluntary. I realize that treatment will not be denied
ifl
refuse to sign
this form.
REVOCATION:
I understand that I have the right to revoke this authorization any time.
If
I revoke this authorization, I understand that I must
do
so in writing and that I must present my revocation to the medical record department. I understand that
th
e revocation will not apply to information
that has already been released
in
response to this authorization. I understand that
th
e revocation will not apply
to
my insurance company, Medicaid
and Medicare.
Client/Representative Signature
Date
Printed Name
Representative's R
el
ationship to C
li
ent
Witness (optional) Date
Client
Name:
ID#:
DOB
:
DH
3203, 11125/08
Original:
To
File
Copy
: To Cl
ient
Copy:
To
Accompany
Di
s
clo
s
ure
(S
tock
Number
:
57
44-000-3203
-1
)
FLORIDA DEPARTMENT OF HEALTH IN MIAMI-DADE
8175 NW 12TH ST SUITE 306 MIAMI, FL 33126
