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Walk-ins are welcome
Same day appointments available
954-983-9191

Consentimiento para la liberación médica


Release copies of my medical records to: Primary Care Physicians of Hollywood

2488 N. University Drive, Pembroke Pines, Fl 33024 - Phone: 954-983-9191 - Fax: 954-983-1152


The facility named above is released from all legal liability that may arise from the release of the information
requested. This authorization is subject to revocation at any time, by written request, except to the extent
that action has been take in reliance thereon, and in any event this authorization expires without express
revocation 90 days from the date that appears below.

Witness
FLORIDA LAW REQUIRES A SPECIFIC AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
PERTAINING TO ALCOHOL, DRUG ABUSE, PSYCHIATRIC AND HIV TESTING. IF ANY OF THESE STATEMENTS
APPLY TO YOUR MEDICAL RECORDS PLEASE SIGN AND WITNESS. IF UNDER 18 YEARS OF AGE, PARENT OR
GUARDIAN MUST SIGN.

I authorize the release of information concerning drug and alcohol abuse.

I authorize the release of information concerning Psychiatric/Psychological treatment.

I authorize the release of information concerning the diagnosis and treatment of HIV test results, AIDS diagnosis and treatment and/or other sexually transmitted diseases.



What makes us Different?

Walk-Ins son bienvenidos

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Or Call 954-983-9191

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Services

  • Asthma Treatments
  • Minor Surgery
  • Immunizations
  • Gynecology
  • Labs
  • Electrocardiograms
  • Pap Smears
  • Fitness Testing
  • Allergy Testing
  • Pulmonary Testing
  • Wound Care
  • Pacemaker Services
  • Dental Services
  • X-Rays
  • Free Transportation
  • Pregnancy Testing
  • Glucose Testing
  • Immigration Services
  • Optometry Services
  • Diagnostics
  • Podiatry
  • Hearing Services