Fillable Form 6033: REQUEST INFORMATION Release of for Authorization

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Form 6033: REQUEST INFORMATION Release of for Authorization

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  • 27 check-boxes
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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
Download
Save PDF to desktop
Email
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Form 6033: REQUEST INFORMATION Release of for Authorization

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Completed 12 August 2020

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