Authorization for Release of Protected Health Information

Medical Records must be picked up in person.

Patient First Name:*
Patient Last Name:*
Address:*

 

Date of Service:*     -To-    
Social Security Number:*
Date of Birth:*
Phone:*
Email:*
I hereby authorize and request Bay Medical to release a copy of the following medical records to:
Name:*
Address:

 

Phone:*
Email:*
Reason for Release:*
Specific Reports Requested:*
I understand that Bay Medical Center (BMC) may charge a fee for the costs of copying ($1.00 per page or $5.00 per CD), mailing or other supplies associated with this request.
I understand treatment, payment, enrollment, and eligibility for benefits are not conditional upon signed release of information authorization.
I understand the recipient of the information can disclose to others, and the provider acting on this authorization can not protect health information after disclosure to a third party.
I authorize the following person to pick up my medical records
I understand and agree that this information may include information relating to: acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection; sexually transmitted diseases (STDs); treatment for drug or alcohol abuse; or mental or behavioral health or psychiatric care, excluding psychotherapy notes. Any release of substance information must be pursuant to 42 CFR. There are other special restrictions which apply to the release of information regarding HIV, abuse reports, etc.
*
Please Note: You must appear in person to sign and date the request and present your photo I.D. in order to obtain Medical Records, this requirement applies even if you are having the records mailed.
I understand that this consent is revocable (unless action has already been taken on this authorization) upon written notice to the Manager of Medical Records, Bay Medical Center, 615 N. Bonita Avenue, Panama City, FL 32401.