RELEASE OF PATIENT RECORDS AUTHORIZATION
I hereby authorize;
SSQ GROUPE FINANCIER (Assurance Collective)
68660-1380839
to release a copy of all my patient records since 1992 containing protected health information to:
xxxxxxxxxx
Attorney at Law
xxxxxxxxxxxxxxxxxxx
xxxxxxxxxxx, U.S.A.
This authorization is given pursuant to Florida Statute 456.057 and HIPAA regulations. I understand that Florida Statute 456.057(10) makes clear that any third party to whom records are disclosed is prohibited from further disclosing any information in the medical record without the expressed written consent of the patient or the patient's legal representatives.
Patient's or Patient's Legal Representative's Signature
Patient's Date of Birth:___________________________________
Date Signed:___________________________________________
Specific description of information to be disclosed:
I would like to receive in writing what information did you base your decision regarding
Serge Morel case from August 14, 1992.
Please forward all documentation to my attention
as soon as possible.
HIPAA compliant