Forms: Release of Information

This form provides authorization to release patient information.


  1. Print the Release of 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 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

Please allow 3-5 business days upon receipt of your signed consent in order for us to process and release the records.