Medical Records Release Authorization

Patient name: __________________________________________

Date of birth: __________________ Phone: __________________

Address: __________________________________________________________

Direction of release

Select one:

☐Send records from Haven Marijuana Doctor to:

Name or organization: ________________________________________________

Address or secure fax/email: __________________________________________

☐Request records from the following provider or organization and send them to Haven Marijuana Doctor:

Name or organization: ________________________________________________

Address or phone/fax: ________________________________________________

Haven Marijuana Doctor

545 & 571 Ave K SE, Winter Haven, FL 33880

Phone: 863-251-5015 | Fax: 407-357-0347 | Email: Info@havenmjd.com

Records authorized

Select the records to release:

☐Records relevant to my medical marijuana evaluation or continuing care

☐Office visit notes

☐Diagnoses and medical history

☐Medication list

☐Laboratory or imaging reports

☐Prior physician certifications or related clinical records

☐Other, specifically: _______________________________________________

Date range: From __________________ to __________________

Information subject to special federal or state protections, including records governed by 42 CFR Part 2, will be handled under those separate requirements. This form does not override a separate consent required for those records.

Purpose

☐At my request

☐Coordination of care

☐Medical marijuana evaluation

☐Other: ____________________________________________________________

Delivery method

☐Secure electronic delivery, if available

☐Mail

☐Fax to a verified number

☐I will pick up a copy

☐Other: ____________________________________________________________

Expiration

This authorization expires on __________________ or when the following event occurs: _______________________________________________. An expiration date or event must be entered.

Your choices

I understand that I may revoke this authorization at any time by sending a written request to Haven Marijuana Doctor, except to the extent action has already been taken in reliance on it. Haven will not condition my treatment or payment for treatment on signing this authorization, except where the law specifically permits a condition. Information disclosed to a recipient outside the protections of HIPAA may be redisclosed by that recipient and may no longer be protected by HIPAA.

I have read this authorization, understand what information it covers, and authorize the release indicated above. I may request a copy of this signed form.

Patient or authorized representative signature: ______________________________

Date: __________________

If signed by a representative

Printed name: _________________________________________________

Relationship and legal authority: _________________________________

For office use: Identity/authority verified by: __________________ Date: __________