Transcription of Medical release authorization - usf.edu
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Medical release authorization - usf.edu
Patient s NameDate of birthPatient s last 4 Number of Social Security Record NameRelationship to PatientRepresentative AddressLegal AuthorityVerification of IdentityVerfication of AuthorityForm# 1107-001 (rev 1/12) authorization to Records Custodianfor the release of Medical Records13330 USF Laurel Drive, MDC 33 Phone (813) 974-9818 Fax (813) 974-4280By signing this form I understand that I am authorizing the designated Medical records custodians or database custodian to use and/or disclose my protected healthinformation (PHI) as defined under 45 CFR , the federal regulations implementing the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) asdescribed below to the following person(s) or organization(s) release to: _____Obtain from: _____NameName_____Street AddressStreet Address_____City, State, Zip CodeCity, State, Zip CodePurpose of requesting records: _____I specifically authorize the use and disclosure of the following PHI: (Please provide a detailed description of the particular data and period of time you arerequesting) Initial next to A, B, or C and circle Medical records in the custody of USF HealthRecords of the treating physicianLast office visit Note, or Medication li
Patientís Name Date of birth Patientís last 4 Number of Social Security No. Medical Record No. Representative Name Relationship to Patient Representative Address Legal Authority Verification of Identity Verfication of Authority
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