Authorization to Release Healthcare Information DigitalAuthorization to Release Healthcare Information Tubal Reversal Experts 2454 N. McMullen Booth Road Suite 601, Clearwater FL 33759 Patient's Name ( First and Last Name / Any Former Last Name )*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number*Patient's Email Address* Hospital Records are Being Requested From*Hospital's Complete Address* Street Address City State Zip Code Hospital (Medical Records) Phone*Hospital (Medical Records) Fax*This Authorization permits the above-named healthcare provider to disclose the following medical records:* Surgery & Pathology Report from my Tubal LigationMonth and year of Tubal Ligation:*Patient's Signature*