This form provides authorization to release patient information.

  1. Download the Authorization to Release 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 and mail your records.

Due to HIPAA Regulations our practice will not fax out records. We will only mail requested records to supplied address on form.