BMC-10044 Rev. 07/20 Page 1 of 1
AUTHORIZATION TO RELEASE
MEDICAL INFORMATION AND
RADIOLOGY IMAGES
PATIENT LABEL
Baptist Medical Center Jacksonville, Jacksonville, FL
Baptist Medical Center Beaches, Jacksonville Beach, FL
Baptist Medical Center Nassau, Fernandina Beach, FL
Baptist Medical Center South, Jacksonville, FL
Baptist Emergency Center Clay, Fleming Island, FL
Baptist Emergency Town Center, Jacksonville, FL
Baptist Emergency Center North, Jacksonville, FL
Baptist Emergency Center Oakleaf, Jacksonville, FL
Wolfson Children’s Hospital, Jacksonville, FL
I am aware that such records may contain information related to mental health, substance abuse (both alcohol and drug) and sexually transmitted
diseases (including test results related to HIV/AIDS), and I specifi cally authorize the release of such information pursuant to this Authorization.
I understand that this Authorization will remain in eff ect for one (1) year, but I may revoke it at any time in writing. I further understand that any such revocation will
not apply to any information already released under this Authorization. I understand that I am under no obligation to sign this Authorization, and that my ability to
obtain treatment from Baptist Health or the above-referenced entity(s) will not depend in any way on whether I sign this Authorization. I understand that I have a
right to receive a copy of this Authorization.
I understand that State and federal law may prohibit the Recipient from re-disclosing information provided pursuant to this Authorization, but that neither Baptist
Health nor the above-referenced entity(s) has any control over the Recipient and cannot, therefore, guarantee that the Recipient will not re-disclose such
information. I hereby release Baptist Health and the above-referenced entity(s) from any and all liability related to (i) their reliance upon this Authorization or (ii) the
release of information pursuant to this Authorization.
Signature of Patient Date Time
If the patient is (i) a minor, the patient’s parent or guardian should consent by signing below, or (ii) an adult but mentally or physically unable to consent for himself
or herself, then the patient’s guardian, legal representative, attorney-in-fact, surrogate or proxy should consent on the patient’s behalf by signing below:
Signature of Representative Date Time Telephone Number
Name of Representative Relationship to Patient
Baptist Facility Who is Releasing Information
K Baptist Medical Center Jacksonville/Wolfson Children’s Hospital
800 Prudential Drive, Jacksonville, FL 32207
Attn: HIM Phone: (904) 202-1169 Fax: (904) 202-2233
K Baptist Medical Center South
14550 St. Augustine Road, Jacksonville, FL 32258
Attn: HIM Phone: (904) 271-6040 Fax: (904) 271-6044
K Baptist Medical Center Beaches
1350 13th Avenue South, Jacksonville Beach, FL 32250
Attn: HIM Phone: (904) 627-2945 Fax: (904) 627-1824
K Baptist Medical Center Nassau
1250 South 18th Street, Fernandina Beach, FL 32034
Attn: HIM Phone: (904) 321-3602 Fax: (904) 321-3615
K Other Facility:
Fax Number:
Address: City, State, Zip Code:
I hereby authorize the above-referenced entity to release the medical information about me indicated below to the following recipient:
To Whom Information Will Be Provided
Entity/Individual: Address:
City, State, Zip Code: Fax Number:
Email Address: Telephone Number:
Patient Name: Birth Date: Medical Record Number:
Address: City: State: Zip: Telephone Number:
Records Being Released:
K Abstract (no images) K Emergency Department Records K Cardiovascular Reports
K History & Physical K Laboratory Results K Operative Reports
K Consultation Records K Radiology Reports (no images) K Anesthesia Records
K Discharge Summary K Pathology Reports K Other:
Images Needed:
K Radiology Images K Ultrasound (Sonogram) Images K CT Scan Images
K Magnetic Resonance Imaging (MRI) Images K Nuclear Medicine Images K Other:
Dates of Service Needed:
K All K Last Visit Only K From: To:
Purpose of Release:
K Continued Care* K Personal K Disability
K Research K Insurance K Department of Children’s & Family Services (DCFS)
K Legal (Attorney) K Other:
* If for continued care, records needed for doctor’s appointment on (date) at (time).
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