Naming convention for scanning: Release/Request of Records
AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION
Planned Parenthood
®
of South, East and North Florida
□ Tallahassee 2618 W Tennessee St Tallahassee, FL 32304 (850) 574-7455…..Fax (850) 575-4335
□ Gainesville 914 NW 13 Street Gainesville, FL 32601 (352) 377-0881......Fax (352) 374-6823
□ Jacksonville 5978 Powers Ave Jacksonville FL 32217 (904) 399-2800…...Fax (904) 399-2525
□ Treasure Coast 1696 SE Hillmoor Dr. Pt. St. Lucie FL. 34952 (772) 692-2023….. Fax (772) 692-1555
□ Mango 2300 N FL. Mango Rd. West Palm Beach, FL (561) 296-4919…..Fax (561) 721-3474
□ Boca Center 8177 Glades Rd, Bay 25, Boca Raton, FL 33434 (561) 226-4116…...Fax (561) 939-1344
□ Pembroke Pines 263 N University Dr, Pembroke Pines, FL 33024 (954) 989-5747……Fax (954) 989-2371
□ Golden Glades 585 NW 161
st
St. Miami, FL 33169 (305) 830-4111…...Fax (305) 830-4101
□ Miami Jean Shehan 1378 Coral Way, Miami, FL 33145, (305) 285-5535…...Fax (305) 285-6956
□ Kendall 8900 SW 117th Ave Suite 207B Miami, FL 33186 (786) 263-0001……Fax (786) 263-0004
CLIENT NAME:
_______________________________________________________________________________________________
LAST FIRST MI MAIDEN OR OTHER NAME
DATE OF BIRTH: _____-_____-_____ SS#: _____-_____-_____ CHART NUMBER #: _____________________
MO DAY YR
ADDRESS: _____________________________________________________________________________________
CITY: ______________________________________________________ STATE: _______ ZIP: _______________
DAY PHONE: _______________________________ EVENING PHONE: ________________________________
I HEREBY AUTHORIZE PLANNED PARENTHOOD OF SOUTH, EAST AND NORTH FLORIDA
OBTAIN or RELEASE MY HEALTH INFORMATION TO or FROM:
(CIRCLE ONE) (CIRCLE ONE)
NAME: ________________________________________________________________________________________
ADDRESS: _____________________________________________________________________________________
CITY: ______________________________________________________ STATE: _______ ZIP: _______________
DAY PHONE: _______________________________________ FAX: ____________________________________
Chart Form #1A
Revised 9/2021
Naming convention for scanning: Release/Request of Records
HEALTH INFORMATION TO BE RELEASED:
I specifically authorize release of information:
______ Visit Summary’s
______HIV test results
______ Pap smear reports
______ STI results (sexually transmitted infections)
______ Biopsy results
______ Ultrasound results
______ Mammogram results
______ Mental Health records or reports
_____ Records from other providers that Planned Parenthood may have in their possession
CONDITIONS OF AUTHORIZATION
1. This Authorization will expire in twelve (12) months after date of authorization unless otherwise noted:
________________________________________________________________________________________________
2. I may revoke this Authorization at any time by notifying PPSENFL Inc. in writing, and it will be effective on the date notified
except to the extent that Planned Parenthood of South, East and North Florida. has already acted upon such Authorization.
3. Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer
protected by Federal privacy regulations.
4. By authorizing this release of information, my healthcare and payment for my healthcare will not be affected if I do not sign
this Authorization form.
5. I have been offered a copy of this signed Authorization form.
______________________________________________ OR _________________________________________
SIGNATURE OF PATIENT AUTHORIZED PERSON
DATE ________________________________________ DATE ____________________________________
DATE REQUEST FILLED: _________________________________ BY: ________________________________
IDENTIFICATION PRESENTED: _______________________________ FORM OF IDENTIFICATION: ________
CONFIDENTIALITY NOTICE: THE INFORMATION CONTAINED IN IS PRIVILEGED AND CONFIDENTIAL INTENDED FOR THE
USE OF THE ADDRESSEE LISTED ON THE FRONT PAGE. THE AUTHORIZED RECIPIENT OF THIS INFORMATION IS PROHIBITED FROM DISCLOSING
THIS INFORMATION TO ANY OTHER PARTY AND IS REQUIRED TO DESTROY (I.E., SHRED) THE INFORMATION AFTER ITS STATED NEED HAS
BEEN FULFILLED. IF YOU ARE NOT THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISCLOSURE, COPYING, DISTRIBUTION,
OR
ACTION TAKEN IN RELIANCE ON THE CONTENTS OF THESE DOCUMENTS IS STRICTLY PROHIBITED (FEDERAL
REGULATION 42 CFR, PART 2, AND 45 CFR, PART 160).
IF YOU RECEIVE THIS ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY BY CALLING THE PHONE NUMBER ABOVE TO
ARRANGE FOR RETURN OF THE DOCUMENTS.
Chart Form #1A
