Authorization for disclosure of health information
Please complete form and fax or mail in the form to our office.
It is of utmost importance to our practice to protect the privacy of our patients. Therefore, we require an authorization signed by the patient or their guardian in order to release medical information. You may complete, sign and return the “Authorization for Disclosure of Health Information” form to our office via fax at 850-916-8499 or by mail to:
1040 Gulf Breeze Parkway
Suite 209
Gulf Breeze, FL 32561.
Also, please review our Notice of Privacy Practices and contact the office if you have any questions or concerns.