Phone No.



7955 Bay St - Suite 2, Sebastian, FL 32958

Record Release Form

I hereby authorize

Entity of Person from whom records are requested:
to disclose my individually identifiable health information as described below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS), mental illness (except for psychotherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such related information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form.

I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider, the released information may no longer be protected by federal and state privacy regulations.
Patient Name (Full legal Name):
MM slash DD slash YYYY
Information to be released:
or Specific item (check all that apply)
Purpose of this broadcast: Continuation of care

The health information described herein shall be released to:

Name: Internal Medicine & Primary Care of Sebastian LLC-Dr. Pierre
Address: 14499 US-1, Sebastian, Florida 32958
Phone 772-783-2436 Email: [email protected]
Send by (Choose One):
I understand this authorization will expire by law 180 days from the date of this authorization unless I otherwise specify. I desire this authorization to be in effect until(Expiration event/date):

I further understand that I have the right to revoke this authorization at any time by notifying Elite Care Clinic in writing. I also understand that the revocation will not apply to the information that has already been released in response to this authorization. A copy of this authorization maybe utilized with the same effectiveness as an original. I am entitled to receive a copy of this authorization.
Name of Patient, Parent, or Legal Guardian: