Authorization to Receive Information Form
This form provides authorization for Pediatric Ear, Nose and Throat Specialists to receive patient information.
- Download the Authorization to Receive Information Form
- Print it
- Complete All sections
- SIGN it
- Send it to us using one of the two methods below:
- Fax completed form to our main office: (727) 329-5401
- Mail completed form to our main office:
PO BOX 76479
St. Petersburg, FL 33734-6479
Please allow 3-5 business days upon receipt of your release in order for us to process the form.