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Dr. Michael Maggard at your service in Dade City, FL

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Release Form

General Medical Records Release and Authorization for Use of Disclosure of Protected Health Information
Name of Patient
First Middle Last
Birthdate
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Phone Number
E-mail
I authorize and request the disclosure of all protected information for the purpose of review and evaluation. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:
- Spectacle Prescription
- Contact Lens Prescription
- All Records on File
- Records from last 3 years
- Other
If other, please be specific:
Expiration of the Authorization
Please initial one
90 days after signature date
No expirations
On the date specified below
Date of Expiration of the Authorization
Date Format: MM slash DD slash YYYY
Please send information FROM:
- MICHAEL L MAGGARD OD
  13930 7TH STREET
  DADE CITY, FLORIDA 33525
  Phone: 352-567-8989
  Fax: 352-567-0116
- Another address
Address to send information FROM:
Name of Provider/Clinic/Organization Street Address City State ZIP Code
Phone Fax
Please send information TO:
- MICHAEL L MAGGARD OD
  13930 7TH STREET
  DADE CITY, FLORIDA 33525
  Phone: 352-567-8989
  Fax: 352-567-0116
- Another address
Address to send information TO:
Name of Provider/Clinic/Organization Street Address City State ZIP Code
Phone Fax
Please select how you would like your records transferred:
- Pick up Record
- Mail Records
- Fax Records
I understand that after the custodian of records discloses my health information, it may no longer be protected by federal laws. I understand the information released in response to this authorization may be re-disclosed to other parties. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.
Patients Signature (Parent or Legal Representative, if applicable)
Date
Date Format: MM slash DD slash YYYY
Witness Signature
Date
Date Format: MM slash DD slash YYYY

If you prefer to print out this form and fill it out manually, it can be downloaded here.

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13930 7th St
Dade City, FL 33525-4904

Phone: (352) 567-8989
Fax: (352) 567-0116

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 5:00 PM
Thursday: 9:00 AM - 5:00 PM
Friday: 9:00 AM - 12:00 PM
Saturday: Closed
Sunday: Closed

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Dade City Eye Care - Located at 13930 7th St, Dade City, FL 33525 Phone: 352-567-8989 https://www.dadecityeyecare.com/

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