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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.
All Medical Records
Limited Records (specify)
Date of Birth
Date of Service
Incident # (office use only)
For the purpose of
Continuing to receive medical care
Information for attorney
Information for the insurance company
Personal use of the patient
The foregoing records shall be disclosed to:
The undersigned individual authorizes the release of records:
Administrator/Executor of Estate
E-Signature of Patient or Authorized Representative
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 that the TTFD charges 15 cents for each one sided copy, 20 cents for two-sided copies, and $1.00 per page for certified copies.
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