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 Att

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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  Health, Information, Authorization, Disclose, Authorization to use, Health to use

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