Authorization to Release Healthcare Information Digital

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*
Social 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 Ligation
Month and year of Tubal Ligation:*
Patient's Signature*