Patient Authorization - Tampa Bay Weight Loss Clinic

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Tampa Bay Weight Loss Clinic

Patient Authorization for release of protected Health Information

Physician of facility name

Street Address

City

State

Zip Code

I hereby request that my medical records be released to

Genesis Medical
9780 N 56th Street, Suite C
Temple Terrace, Florida 33617

Please select from the below all that apply

Please fax medical records to: 813-549-7399

Date of request

Patient Name

Patient's Date of Birth

Social Security #

Patient's Signature