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Patient Representation Release

Releasing Millennium Physician Group Information

This form is required for releasing your medical information to your Representative(s). 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

First Name:  
Last Name:  
DOB:  
Email:  
 

Patient Representative Information

I authorize my physician and/or other attending physicians of Millennium Physician Group to release my protected health information/film, and/or, discuss my care/condition with the following individuals:
Name:  
Relationship:  
     
Name:  
Relationship:  
     
Name:  
Relationship:  
     
Patient Signature:  
    (if submitting electronically, type name)

This authorization shall be in effect for one year from the date issued.
 

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

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