Tubal Reversal Experts Authorization For Release Of Confidential Medical Information
Type your information into this form, print and send it to where you had your Tubal Ligation
I,
authorize
(Print patient's name)
(Print name of hospital or doctor's
office)
to release a copy of my medical information from my Tubal Ligation and a copy of my pathology report to:
Dr. Edward Zbella / Dr. Mark Sanchez
Tubal Reversal Experts
2454 McMullen Booth Road, Suite 601
Clearwater, FL 33759
I,
give my authorization for these documents to be
faxed to (727) 796-8764 along with this request.
The date of my tubal ligation was:
My name at the time of my tubal ligation was:
My current name is:
My date of birth is:
My current address:
Address line 2:
My home phone:
My work phone:
My cell phone:
My email address:
__________(initial) I understand that I have the right
to withdraw my authorization at any time except to the extent that
action has already been taken pursuant to this authorization. I
understand that if I revoke this authorization, I must do so in
writing and present my written revocation to the Medical Records
Department.
__________(initial) I understand that authorizing the
disclosure of this health information is voluntary, I can refuse to
sign, and future treatment, payment, or eligibility for benefits
will not be based on whether or not I provide authorization for the
requested use or disclosure. I understand that the recipient may be
prohibited from disclosing substance abuse information. I understand
that I may inspect or copy the information to be disclosed (with a
reasonable charge).
__________(initial) I understand that
information used or disclosed pursuant to this authorization may be
subject to redisclosure by the recipient of the information and is
no longer protected by federal confidentiality laws. Unless
otherwise revoked, this authorization will expire six months from
the date of the signature listed
below.