Forms: Release of Information
This form provides authorization to release patient information.
- Print the Release of Information Form
- Complete all sections
- SIGN it
- Send it to us using one of the three methods below:
- Call our office to initiate a 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
- Call our office to initiate a secure email. Once received, attach completed form
Please allow 3-5 business days upon receipt of your signed consent in order for us to process and release the records.