Patient Authorization Form

Patient Authorization for Use and Disclosure of Protected Health Information

Patient First Name *

Patient Last Name *

Email Address *

Phone Number *

Birth Date *

Maiden/previous/other names *

This Will Authorize The Following Providers

Provider or Practice Name

Address *

Telephone *

Fax

To Release Information Selected Below To:

Julia Barriga, M,D.,P.A.5001 E.

5001 East Busch Blvd Tampa, FL 33617 | Phone (813) 984-8846, Fax (813) 984-8827 | DSM: barrigamd@juliabarrigamd.opdirect.net

INFORMATION REGARDING

All medical records

Operative reports

Mental health records

Audiological

Ear, Nose, Throat

Consultations

Education (IEP)

Neurologic

Specialist Reports

History and physical

Treatment plan

Ophthalmology

Orthopedic

Immunizations

Allergies

X-Ray and Lab Reports

ER Reports

Physical form

Other

Medical Reports from

PURPOSE OF RELEASE (CHECK ALL THAT APPLY)

Treatment/Referral

Insurance purposes

Personal use

Change of physician

Patient Authorization Form

Patient Authorization for Use and Disclosure of Protected Health Information

IF YOU ARE CHANGING PHYSICIANS, PLEASE MARK THE REASON (CHECK ALL THAT APPLY):

Prefer different office location

Problems with office staff

Moving out of town

Prefer different physician

Physician not in your network

Age of children

Inadequate appointment availability

Other (specify)

INFORMATION TO OMIT (CHECK ALL THAT APPLY)

Mental health records

HIV records

Substance abuse (Alcohol/Drugs) records

Other

I understand that if the organization authorized to receive the information is not a health plan or healthcare provider the release of the information may no longer be protected by Federal privacy regulations. I understand that I need not sign this authorization to ensure treatment. This authorization shall valid for six months from the date signed below. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the department or facility listed on the authorization. I understand that that revocation will not apply to information that has already been released in response to this authorization. I understand that revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

I authorize the use and disclosure of the medical records and health care information indicated above (please print):

Print Name

Relationship to patient if not signed by patient

Current address

Current home phone

Current work phone

Today’s date

This authorization will expire on

Signature (Patient must sign if 19 years of age or over; otherwise parent, or legal representative)

Use your mouse or finger to sign in the box below.

PLEASE NOTE: THERE WILL BE A $.25 PER PAGE CHARGE FOR COPYING RECORDS ($25 MAXIMUM).

(NOTE: The person signing this authorization is to be provided a copy of this form. If the records being released are for a patient who is 19 years of age or over at the time of the record request, the patient must sign this form.)

Julia Barriga M.D. P.A.

Julia Barriga M.D. P.A.

New Patient Enrollment

Patient Authorization Form

This Will Authorize The Following Providers

To Release Information Selected Below To:

Julia Barriga, M,D.,P.A.5001 E.

5001 East Busch Blvd Tampa, FL 33617 | Phone (813) 984-8846, Fax (813) 984-8827 | DSM: barrigamd@juliabarrigamd.opdirect.net

INFORMATION REGARDING

PURPOSE OF RELEASE (CHECK ALL THAT APPLY)

Patient Authorization Form

Patient Authorization for Use and Disclosure of Protected Health Information

IF YOU ARE CHANGING PHYSICIANS, PLEASE MARK THE REASON (CHECK ALL THAT APPLY):

INFORMATION TO OMIT (CHECK ALL THAT APPLY)

Julia Barriga M.D. P.A.

Julia Barriga M.D. P.A.

New Patient Enrollment

Patient Authorization Form

This Will Authorize The Following Providers

To Release Information Selected Below To:

Julia Barriga, M,D.,P.A.5001 E.

5001 East Busch Blvd Tampa, FL 33617 | Phone (813) 984-8846, Fax (813) 984-8827 | DSM: barrigamd@juliabarrigamd.opdirect.net

INFORMATION REGARDING

PURPOSE OF RELEASE (CHECK ALL THAT APPLY)

Patient Authorization Form

Patient Authorization for Use and Disclosure of Protected Health Information

IF YOU ARE CHANGING PHYSICIANS, PLEASE MARK THE REASON (CHECK ALL THAT APPLY):

INFORMATION TO OMIT (CHECK ALL THAT APPLY)

Forms Sent!