Forms: Information Authorization

This form provides authorization for Pediatric Ear, Nose and Throat Specialists to receive patient information.

1. Print the Authorization to Receive Information Form
2. Complete all sections
3. SIGN it
4. Send it to us using one of the three methods below:
   • Call our office to initiate secure email. Once received, attach completed form

     Note: Recipients can send a secure reply and any content or attachments will be encrypted

   • Fax completed form to our main office: (727) 329-5401
   • Mail completed form to our main office:
     PO BOX 76479
     St. Petersburg, FL 33734

      

     Once we receive your signed consent, our office will fax the form to the Outside Facility/Physician.