Record Request: Authorization to Use and Disclose ...

Authorization for Use or Disclosure of Protected Health Information*RI0001*RI0001 Revised 5/30/19PS46283 Phone # h Check if patient is an employee of UF Health Shandsh UF Health Shands Hospitalh UF Health Shands Rehab Hospital h UF Health Shands Psychiatric Hospitalh UF Health Florida Recovery Centerh UF Health Clinics Specific Clinic: _____h UF Health Shands HomeCare 1610 NW 23rd Avenue, Gainesville, FL 32605 Phone: Fax: Health HIM Dept Box 100348 Gainesville, FL 32610-0348 Phone: : check appropriate facility and mail or fax completed forms to:h Specialty, Physician or Hospital: Clinic, person or organizationAddressPhone Attn h Check here if same as patient h Check here for records pick-up onlyClinic, person or organizationAddress FaxPhone AttnThe following PHI may be released (check boxes below):I further authorize the release of the following information which may be included in the PHI:Is this needed for adoctor s appointment?

This authorization allows UF Health to use and disclose (release) certain PHI, which includes medical records, as I have directed. I understand that: •The PHI may include information about mental health, substance and/or alcohol use, HIV/AIDS, and STDs.

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  Authorization, Disclose, To use, Authorization to use

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