Release Form Draft

1. PATIENT INFORMATION- I authorize the release of medical information.

Name*

First Middle Last

Email

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

2. AUTHORIZATION FOR RELEASE. I understand that MMTC will not condition treatment, payment, enrollment or eligibility for benefits.

Medical Marijuana Treatment Clinics of Florida LLC- Records Administration 1639-2 Village Square Blvd., Tallahassee, FL 32309 FAX: (850) 296-1872

Please Select One*

Please select one

Request Health Information FROM
Send Health Information TO

The person named above authorizes information to be requested or released by representatives of

Name Of Provider, Facility, OR Person*

Name of Provider

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax Number

3. PURPOSE OF REQUEST. To obtain prior patient diagnosis for medical cannabis evaluation.

*

Coordination of Care

4. RELEASE THE FOLLOWING INFORMATION

Please select all that apply*

5. SPECIFIC AUTHORIZATION. I specifically authorize the release of ALL medical information relating to the above named patient including but not limited to the following categories protected by state or federal law: (1) Substance abuse (drug or alcohol) treatment; (2) Mental health treatment; and (3) HIV-AIDS-related information, if such information is contained in the records. This authorization includes reports, clinical notes, correspondence, test results, and any other information in the records, whether generated by the authorized provider or another entity. The above provider/organization, its employees, representatives and any other person performing services for them or on their behalf, may need to obtain, use and disclose any and all information about physical and mental health, including but not limited to, services for preventative, diagnostic and therapeutic care, tests, counseling, and medical prescriptions. Confidentiality of this information is protected by federal law (HIPAA and 42 CFR Part 2).

6. REDISCLOSURE. This release does not authorize re-disclosure of medical information beyond the limits of this consent. The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party without further authorization. I specifically understand and agree that the re-disclosure requirements set out above will apply to these records.

7. VALIDITY. I understand that this authorization will automatically expire one year from the date of my signature, and that I may revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above. I agree that any release which has been made prior to revocation and which was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality. You have the right to inspect the information you are authorizing to be re-released. The information you are authorizing to be released could be re-released or disclosed by the recipient. Such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with information released as a result of this authorization.

I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my signature below. I am entitled to a copy of this authorization.

Printed Name of Patient or Authorized Representative*

Date

Email

This field is for validation purposes and should be left unchanged.