Records Release Authorization
Authorization to Use and Disclose Confidential Information

Neurovations Neurology Clinic

Records Release Authorization

Authorization to Use and Disclose Confidential Information

Purpose of Disclosure:

Neurovations Neurology Clinic requests medical records from other providers to assist in providing comprehensive care to the patient. This authorization allows Neurovations Neurology Clinic to obtain necessary medical records relevant to the patient’s neurology treatment.

Request for Records from Other Providers

Neurovations Neurology Clinic requests that the following information be disclosed from the provider/facility listed below:

Specific Records Requested (circle all that apply)*office use only*

• Any/All Medical Records

• Office Notes

• Operative Reports

• History and Physical

• Consultations

• Progress Notes

• Radiology Reports

• Problem List/Medication List

• Lab/Pathology Reports

• Other:_________________________________________________

  
  

  Please Note:

  • I understand that the information may include details about mental health, substance and/or alcohol use, HIV/AIDS, and sexually transmitted diseases (STDs).

  • Duration of Authorization: This authorization will remain in effect for one (1) year from the date of signature or until I revoke it in writing, whichever comes first.

  • Right to Revoke: I understand that I have the right to revoke this authorization at any time. I understand that revocation will not apply to information already released in response to this authorization.

  • Redisclosure Notice: I understand that once the above information is disclosed, it may be re-disclosed by the recipient, and the information may no longer be protected by federal or state privacy laws. Neurovations Neurology Clinic, its employees, officers, and physicians are hereby released from any liability for the disclosure of the above information as authorized in this document.

  • Voluntary Completion: I understand that completing this authorization is voluntary and that refusal to sign will not affect my ability to obtain treatment at Neurovations Neurology Clinic.

  • Fee Notice: I am aware that I may be charged a fee for this request as permitted by Florida law, which may include up to $1.00 per page for paper records and additional fees for supplies and postage. Fees are waived when information is released to a healthcare provider for treatment purposes.

    
    

Fax Records to: 407-975-1247

Email: Info@neurovationsclinic.com

Mail to: Neurovations Neurology Clinic 2200 Lee Rd Winter Park, FL 32789

Patient Authorization: