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

  1. Download the Authorization to Receive Patient Information
  2. Print it
  3. Complete All sections
  4. SIGN it
  5. 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.