Records Release Form More Forms New Patient PackageDemographicMedical HistoryMedications ListFinancial PolicyHIPAA ConsentNotice of Privacy PracticesRecords Release Records Release AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATIONI hereby authorize Jose A Gaudier, MD, PA to obtain the following information for the health record(s) of:Patient Name* First Middle Last Patient SSN Last 4 Digits*DOB*To obtain the following reports for the purpose of continuation of care: Please uncheck any that don't apply. Last 3 progress/physician notes Echo/Carotid Ultrasound Laboratory Reports NCV/ EMG Reports Operative/ Pathology Reports History & Physical Consultations Discharge Summary Radiology Studies Information to be obtained from:Name of Physician First Last Facility NamePhoneFax NumberI 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. Patient\Legal Representative Name First Last Date Signature of Patient or Legal Representative:*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!
