Authorization
for
Release
of
Information
Urgent
Care
Center
315
75th
St.
W.,
Bradenton,
FL
34209
P:
941-761-1616
F:
855-876-6218
Imaging
Center
315
75th
St.
W.,
Bradenton,
FL
34209
P:
941-761-8828
F:
941-761-9527
Internal
Medicine
315
75th
St.
W„
Bradenton,
FL
34209
P:
941-792-2211
F:
855-622-2362
General
Surgery
315
75th
St.
W.,
Bradenton,
FL
34209
P:
941-795-3600
F:
855-521-2857
Rheumatology
315
75th
St.
W.,
Bradenton,
FL
34209
P:
941-792-8329
F:
855-521-2857
Neurology
&
Neurosurgery
7005
Cortez
Rd.
W.,
Bradenton,
FL
34210
P:
941-750-0602
F:
855-637-3923
Cortez
Road
Family
Medicine
7005
Cortez
Rd.
W.,
Bradenton,
FL
34210
P:
941-792-2122
F:
855-637-3920
Continuity
Clinic
Blake
Primary
Care
7005
Cortez
Rd.
W.,
Bradenton,
FL
34210
P:
941-752-2882
F:
844-251-9590
Bayshore
Family
Medicine
6033
26th
St.
W.,
Bradenton,
FL
34207
P:
941-752-2025
F:
855-817-7456
Physical
Therapy
&
Physiatry
4110
Manatee
Ave.
W.,
Bradenton,
FL
34205
P:
941-748-8383
F:
855-423-5096
REQUEST
INFORMATION
I
Hereby
Authorize
Pinnacle
Medical
Group
s
______________________
(Select
from
above)
to
REQUEST
information
FROM:
Doctor/Facility
Name
and
Address:________________________________________________________________________
Phone
#:
______________________________________________
Fax
#:
______________________________________
RELEASE
INFORMATION
I
Hereby
Authorize
Pinnacle
Medical
Group
s
______________________
(Select
from
above)
to
RELEASE
information
TO:
Doctor/Facility
Name
and
Address:________________________________________________________________________
Phone
#:
______________________________________________
Fax
#:
______________________________________
REGARDING
THE
FOLLOWING
PATIENT:
Name:
____________________________________________________________________
Phone
#:
___________________
Address:
_______________________________________________________________
Date
of
Birth:
___________________
Records
to
be
Released:
Date(s)
treatment
was
received:
___________________________________________
Consultative
Report
History
and
Physical
Laboratory
Report
Operative
Report
Pathology
Report
Progress
Notes
X-Ray
Film
X-Ray
Report
Photographs,
Videos
Digital
or
Other
Images
Entire
Record
Certified
Copy
Other
____________________________________
I
authorize
the
release
of
information
relating
to:
HIV/AIDS
Testing/Treatment
Psychiatric
Evaluation/Treatment
Alcohol/Drug
Abuse
Evaluation/Treatment
Purpose
of
Release:
Continuing
care
for
ongoing
treatment
Transfer
of
Care
Other
________________________________________
This
authorization
expires
on
the
following
date,
event
or
condition:
__________________________________________
.
If
I
do
not
specify
any
expiration
date,
event
or
condition,
this
authorization
will
expire
in
one
year.
Statement
of
Authorization:
I
understand
that,
except
for
research-related
treatment,
Pinnacle
Medical
Group
will
not
condition
my
treatment,
payment,
enrollment,
or
eligibility
for
benefits
on
my
signing
this
authorization.
Except
to
the
extent
that
action
has
already
been
taken,
I
understand
that
I
may
revoke
this
authorization
at
any
time
by
giving
written
notification
to
Pinnacle
Medical
Group
(Medical
Records).
A
photocopy/fax
of
this
authorization
will
be
treated
in
the
same
manner
as
the
original.
I
do
not
authorize
further
release
to
any
third
party.
I
understand
that
once
information
is
released
as
specified
in
this
authorization,
the
facility,
their
employees
and
my
physician(s)
cannot
prevent
the
re-disclosure
of
that
information.
I
hereby
release
each
of
them
from
any
and
all
liability
arising
directly
or
indirectly
from
disclosure
authorized
by
this
consent
and
any
re-disclosure
of
that
information.
Signature
of
Patient/Legally
Authorized
Representative
Date
Relationship
to
Patient
Reason
Patient
Unable
to
Sign
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