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Send Medical Records to Another Recipient

I hereby request and authorize the following release of information:

Information to be release by:
PRIMARY CARE PHYSICIANS OF HOLLYWOOD
2488 N. University Drive • Pembroke Pines, FL 33024
PHONE: 954-983-9191 • FAX: 954-983-1152

Information to be released to:


INFORMATION TO BE RELEASED:

My health information relating the following condition or treatment:

PURPOSE FOR DISCLOSURE:

INCLUDE the following information from my records released (please initial)

I understand that my records may contain information regarding the following sensitive diagnosis or treatment. If
the item is initialed, then I give my specific authorization for these records to be released.

MY RIGHTS

I understand that I do not have to sign this authorization in order to get health care benefits (treatment, payment, or
enrollment). However, I do have to sign an authorization form in order to take a part in a research study OR to receive
health care when the purpose is to create health information for a third party.
The facility named above is released from all legal liability that my 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 taken
in reliance thereon, and in any event this authorization expires without express revocation 90 days from the date that
appears below.



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Walk-ins are welcomed
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