*Pursuant to Florida
Administration Code 64B-10.003 we reserve the right to charge for the release
of medical records.
Records are to be sent to:
475 Osceola Street
Fax (407) 831-1068
I understand that this
consent is revocable upon written notice to the office where the original
authorization is retained, except to the extent that action has already been
taken on this authorization, and that the office has been taken in reliance on
this authorization, and that consent shall remain for one year unless otherwise
specified in order to affect the purpose for which it is given. Mental health,
alcohol, drug abuse, HIV, & or AIDs information is
confidentially protected by Federal and State Law which prohibits disclosure
without specific written authorization of the undersigned, or as otherwise
permitted by such regulations.
I, the requester for
this medical record release, warrant the truthfulness of the information
provided in this form.