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*190003* Protected Health Information*

Form # 190003 Page 1 of 1 Authorization to Use and Disclose Protected Health Information* *190003*Approved: 01/2015 Revised: 02/16/15 Patient Name Patient's AddressDate of BirthMedical Record #Phone #Last 4 digits of SSN (Optional)Check if patient is an employee of UF HealthVerification of IdentityZipCityStateDriver's License/State ID Personally known Other Complete the section below only if the person requesting records is not the patient: Name of Representative Representative's Address & Phone NumberRelationship to PatientVerification of IdentityLegal AuthorityVerification of AuthorityBy signing this form, I authorize the release of PHI ( , medical records) as follows: From the doctor, office, facility or other Health care provider checked or written below: Shands Jacksonville Medical Center, Inc., d/b/a UF Health Jacksonville 655 W 8th Street, Jacksonville, FL 32209 Phone: 904-244-2596 Fax: 904-244-3165 Elizabeth G.

Form # 190003 Page 1 of 1 Authorization to Use and Disclose *190003* Protected Health Information* Approved: 01/2015 Revised: 02/16/15 Patient Name

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