Request and Authorization for Disclosure of Health Information Form
City of Marco Island Fire Rescue Department
50 Bald Eagle Dr.
Marco Island, FL 34145
(239) 389-5040
(239) 393-0099—Fax
http://www.cityofmarcoisland.com/index.aspx?page=140
In compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, a patient has the right to
access, inspect and copy their Protected Health Information (PHI) maintained by City of Marco Island Fire-Rescue.
Additionally, your rights allow you to request a copy, request to amend and/or request restriction of the use of any
disclosure of your PHI.
This is an authorization requesting the City of Marco Island Fire-Rescue Department to release medical reports and/or
information protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) or by state law
protecting the privacy of health information.
I, ____________________________, hereby authorize the use and disclosure of the individually identifiable health
information to be furnished to the requesting party below.
REQUESTING PARTY INFORMATION
Name _______________________________________________________ Date of Request ___________________
Mailing Address ___________________________________________________________________________________
Apt./Suite # City State Zip Code
Phone Number ____________________
PATIENT INFORMATION
Name on Report _________________________________________________________________________________
Patient Date of Birth ______________________________________ Patient SSN __________________________
Location of Incident ________________________________________ Date of Incident _______________________
Type of Incident ____________________ Incident Number (if known) _______________________
This authorization shall be in force and effect until ____________________________ at which time this authorization to
use or disclose this protected health information expires.
x _________________________________________________
Signature of Patient or Personal Representative
Relationship to Patient _______________________
STATE OF __________________
COUNTY OF _______________________
The foregoing instrument was acknowledged before me this _______ day of _____________, 20___,
by _________________________________
.
Personally Known ____ or Produced Identification____ Type of Identification Produced_____________
(NOTARY SEAL)
__________________________________________
Notary Public
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