Authorization Release

Required Optional Completed
Choose Location
Choose Physician
Submitter Information
Patient Information
Sending Practice Information
or
Sending Practice Information
Receiving Practice Information
What’s the purpose of this request?
Authorization of Usage and Disclosure

By Selecting, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records,
If Such Information And/or Records Exist:

Restrict Disclosure

Do you want to restrict disclosure for any records related to the following?
If no please continue to next step

(Federal regulations require a description of how much and
what kind of information is to be disclosed.)
Consent
I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

I also understand that the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.

I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization.

Finally, I understand that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization.
Location Information
Location Name
Physician Name
Submitter Information
Your Name
Signed Authorization Release File
Phone Number
Email Address
Patient Information
First Name
Last Name
Patient Date of Birth
SSN
Sending Practice Information
Company Name RTP-MEDSOL
Contact phone (407) 617-2692
Street 7037 Rose Ave
City Orlando
State Florida
Zip 32810
Upload to RTP Document Portal

Upload to RTP Document Portal
Fax
Email
Sending Practice Information
Name Of Practice
Phone Number
Street
City
State
Zip
Receiving Practice Information
Name Of Practice
Phone Number
Street
City
State
Zip

Receiving Practice Information

Company Name RTP-MEDSOL
Contact phone (407) 617-2692
Street 7037 Rose Ave
City Orlando
State Florida
Zip 32810
What’s the purpose of this request?
Authorization of Usage and Disclosure

By Selecting, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records, If Such Information And/or Records Exist:

Restrict Disclosure

Do you want to restrict disclosure for any records related to the following? If no please continue to next step

Consent
I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

I also understand that the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.

I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization.

Finally, I understand that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization.
Confirm your Information