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Medical Information Request

This form is required for obtaining 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 obtain your medical records or other information from the sources referenced below.

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
First Name:
 
Last Name:
 
Birth Date:
 
 

Obtain Medical Information From
Facility Name:
 
Address:
 
City:
 
State:
 
Zip:
 
Email Address:
  
 

Select the Information you would like to disclose
  Disclose my protected health information
  Disclose information provided from other sources
 

Disclose Medical Information To
    Millennium Physician Group
    19531 Cochran Blvd.
    Port Charlotte, FL 33948
FAX:
  941-766-7999
Doctor:
 
     
Requested Information:
 
 
     
Purpose For Requested Information:
 
 

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.
  Refuse to sign this authorization.

If you have any questions regarding this release of protected information, please ask to speak to a Medical Records representative at 941-255-3535.

Patient Signature:
 
(if submitting electronically, type your name)
Date:
 
Patient or Personal Representative:
 

(if applicable)
(if submitting electronically, type your name)
 

By submitting this form to Millennium Physician Group, I agree to all the Terms & Conditions stated above.

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