Records Release Form

Records Release


  • I hereby authorize Jose A Gaudier, MD, PA to obtain the following information for the health record(s) of:
  • To obtain the following reports for the purpose of continuation of care: Please uncheck any that don't apply.
  • Information to be obtained from:

  • I understand that this authorization if voluntary and that I may refuse to sign this authorization. All information will be held confidential and cannot be released to any other third party. I understand that this information may refer to diagnosis related to any drug use, alcohol use, psychiatric problems, and/or HIV/AIDS. I understand I may withdraw this consent at any time.
  • Please fax all requested documents to (352)867-7895. If you have any questions when processing this request please contact our office at (352)732-8630. Thank You!