Manatee Primary Care Associates, llc 5225 Manatee Ave. West


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MPCA-007  (8/12) 

Manatee Primary Care Associates, LLC 

5225 Manatee Ave. West

 

Bradenton, FL 34209 



Phone: (941) 708-8081

 

Fax: (941) 708-8085



 

 

A

UTHORIZATION TO 

U

SE AND 

D

ISCLOSE 

H

EALTH 

I

NFORMATION

 

P

LEASE 



R

EAD AND 


C

OMPLETE THE 

E

NTIRE 


F

ORM


 

 

P



ATIENT 

N

AME

 

 



P

ATIENT 

A

DDRESS

:  

__________________________ 

D

ATE OF 

B

IRTH

 

 



 

 

S

OCIAL 

S

ECURITY

: 

 

 



T

ELEPHONE

:

 

 

(

         

) 

 

 



I authorize Manatee Primary Care Associates, LLC to use and disclose a copy of the specific 

health and medical information described below: 

(List specifically the information to be released):



 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



(   )  Send my records to:   

(   )  Obtain my records from: 

 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



Name of Physician or Facility 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



 

Complete 

Street 

Address 


  City 

   State 

 Zip 

Code 


 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



Telephone/Fax No. 

Purpose:  

(   ) Continued Medical Care  (   ) Personal Use 

(   ) New Patient Appt. on:   

 

 



If we are requesting this Authorization from you for our own use and disclosure or to allow another health care 

provider or health plan to disclose information to us: 

 

We cannot condition our provision of services or treatment to you on the receipt of this signed 



Authorization; 

 

You may inspect a copy of the protected health information to be used or disclosed



 

You may refuse to sign this Authorization; and, 

 

We must provide you with a copy of the signed Authorization. 



You have the right to revoke this Authorization at any time, provided that you do so in writing and except to the 

extent that we have already used or disclosed the information in reliance on this Authorization. 

5-Hole 1/4 1 3/8 c-to-c


MP

CA

-00



7  (

8/1


2) 

 

I und



erstand that my re

co

rd may contain i



nformat

ion about a

lcoh

ol and/or drug tre



atment,

 mental 


health or psy

chi


atric tr

eatment,


 and/or HIV

/AID


S info

rmatio


n.  I do here

in ex


pre

ssly and 

volunta

rily 


consent to the dis

clo


sure of my heal

th 


in

formation, 

as spe

cified, for the pur



pose or need a

s in


dic

ated 


above.

 

 



I und

erst


and M

anat


ee Prim

ary Care Associa

tes, L

LC m


ay u

tiliz


e a m

edical record

correspondence service and agree 



to

 pa


y the

 fee assessed by

 this service

.   


 

P

LEASE A

LLOW 

7

 TO 

10

 BUSIN

ESS D

AYS FO

R RE

CORDS TO BE C

OPIE

D

 

 

I have 



review

ed an


d I 

underst


and 

this 


Authoriz

ation.


  I a

lso und


ersta

nd tha


t the infor

mat


io

used or discl



osed

 pursuan


t to

 this Au


thori

za

tio



n ma

y be subj

ect to

 re-disc


lo

sure by the 

recipient and no 

lo

nger protec



te

d under federal l

aw



 



 

 

 



 

 

 



 

 

 



 

 

 



 

 

 



 

Signature of Pa

tien

t/Legal


 Represent

ativ


 

Rela



tionship 

to

 Pa



tie

nt 


 

Date


 

 

 



 

 

 



 

 

For Office Use Only: 

 

Date Request Received: 

 

 

 

 

Medical Record Number: 



 

 

 

 

 



 

 

C

OST OF 

R

EPRO

DUC

IN



M

EDIC

AL 

R

ECORD

S

 

64B8-10


.003

 

Co



sts o

f Reprod


uc

ing Medi


cal Records: 

1. 


Any

 perso


n licensed p

urs


ua

nt t


o C

hapt


er 458,

 F.


S., req

uired t


o release c

opies o


f pat

ient medical rec

ords 

may condi



tion su

ch release u

pon pay

men


t by

 th


e requ

esting p


art

y of t


he 

reasonable cost

s of 

reproducing th



e records.

 

2. 



Reason

ab

le



 co

st of rep

ro

duc


in

g co


pies 

of writ


te

n or


 typed do

cu

ments or r



epo

rts s


hall no

t be more 

th

an 


th

e follo


wing:

 

a) 



For th

e first 25 pages

, t

he cost


 shall be $1.00

 per pa


ge. 

b) 


For each page in

 excess 


of 25 pages,

 th


e cost shall be 25 cent

s. 


3. 

Re

asonable cost



s of repr

oducing x-rays

, and s

uch ot


her special kinds of records shall be t

he act


ual 

costs.


  The phrase “act

ua

l costs” mea



ns t

he cost


 o

f t


he mat

eria


l and su

pplie


s used to

 du


plicate 

th



record, as w

ell as t


he lab

or co


sts and overhead

 co


sts ass

ociat


ed with

 such duplicat

ion. 

 

Cre



dit(

s):


 

Specific A

uth

ority 458



.30

9 FS.


 Law

 Im


plemen

ted 455.674

, 4

55.677


, 458

.331


(1)

 FS.


  Histor

y –


 Ne

w 11/


17/8

7, 


Am

ended 5/12

/88, Form

erly 21M


-26

.003


, 61f6-

26.0


03, 59r-10

.00


3. 

 

5-Hole 1/4 1 3/8 c-to-c




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