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Medical Record Request
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Temple Terrace Fire Department Medical Record Request
Authorization For Use or Disclosure of Health Information
I hereby request and authorize the Temple Terrace Fire Department to release the following records.
Personal Information
All Medical Records
Limited Records (specify)
Specify
First Name
*
Last Name
*
Date of Birth
*
Date of Service
*
Upload ID
*
Incident # (office use only)
Incident Location
*
For the purpose of
*
Continuing to receive medical care
Information for attorney
Information for the insurance company
Personal use of the patient
Other
The foregoing records shall be disclosed to:
First Name
*
Last Name
*
Address1
*
Address2
City
*
State
*
Zip
*
Email
*
Telephone Number
*
The undersigned individual authorizes the release of records:
Patient
Parent
Legal Guardian
Authorized Representative
Spouse
Administrator/Executor of Estate
Other (specify)
Specify
E-Signature of Patient or Authorized Representative
*
Date Signed
*
Print Name of Patient or Authorized Representative
*
* I understand that by signing this authorization, I authorize the Temple Terrace Fire Department to disclose the information identified above and related information necessary to accomplish the purpose described.
* I understand that I will be required to provide the TTFD with identification and if I am not the patient or parent thereof, other documentation is reasonably required by the Department to establish my legal authority to execute this authorization.
*I understand that I may revoke this authorization at any time by submitting a written request to the Department , except to the extent that the Department has already taken action in reliance on this authorization. I understand if I do take action to revoke this authorization, it will expire automatically 60 days after the date of signature.
* I understand that the information disclosed under this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations and other privacy laws.
*I understand TTFD charges $1 per page for any records 15 pages or more.
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