Medical Information Release
Releasing Millennium Physician Group Information
This form is required for releasing your medical information. You can print this form, fill it out and fax it to 941-766-7999 or you can submit this form electronically. By submitting this form by fax or electronically you are authorizing Millennium Physician Group to release your medical records or other information that may be in your file.
We value your privacy and want you to be informed of how we may use and disclose your protected health information. For specifics about our policies, read our Privacy Statement. All electronic data submitted through this website is encrypted and in compliance with HIPAA Regulation.
Patient Information |
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| Last Name: |
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| Birth Date: |
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| Phone Number: |
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| Email: |
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Select the Information you would like to disclose |
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Disclose my protected health information |
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Disclose information from sources other than Millennium Physician Group |
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Forward My Medical
Information To: |
| Facility or Name: |
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| Address: |
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| City: |
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| Requested Information: |
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This information may include confidential material
related to psychiatric or psychological information, infectious or
contagious disease (including HIV/AIDS) information and/or
information about drug or alcohol abuse or treatment. |
| Purpose for releasing
this information: |
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Patient
Authorization |
I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to Medical Records Dept., at Millennium Physician Group, 19531 Cochran Blvd., Port Charlotte, FL 33948. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. This authorization shall expire one year from the date issued. I understand that I have the right to inspect or copy the protected health information to be used or disclosed as permitted under federal or state law to the extent the law provides.
Copying a complete medical record is provided by an outside
copying service at a fee of $1.00 per page to $25.00 and $.25 per
page thereafter. Complete records are mailed and billed directly
to either requesting patient or facility.
If you have any questions regarding this release of protected
information, please ask to speak to a Medical Records
representative at 941-255-3535.
I further authorize Millennium Physician Group to release my protected health information/films to, and/or discuss my care/condition with: |
| Name: |
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| Relationship: |
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| Patient Signature: |
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| (if submitting electronically, type
name) |
| Date: |
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| Personal Representative Signature: |
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(if applicable) |
| (if submitting electronically, type
name) |
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By submitting this form to Millennium Physician Group I agree to all the
Terms & Conditions stated above. |
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