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Florida Center for Infectious Diseases
Infectious Diseases
(904) 292-0863
13241 Bartram Park Blvd., Ste. 1001 Jacksonville, FL 32258
13241 Bartram Park Blvd., Ste. 1001
Jacksonville, FL 32258
(904) 292-0863
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Infusion Center
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Home
About My Doctor
Infusion Center
Specializing In
Patient Forms
Contact
Medical Records Request Form
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Medical Records Request Form
Please fill this form once for each records request we are making on your behalf.
Requesting Records From
Doctor or Practice Name
Phone
Fax
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Specify Which Records
I hereby request that copies of the following medical records be released to the Florida Center For Infectious Diseases INC.
Lab Results
Culture Results (Urine, Sputum, etc)
Imaging Studies (X-rays, CT, MRI, etc)
Serology Studioes (Elisa, IgG, IgM, Western Blot)
Cardiovacsular Studies (Echo, Stress Test, EKG, Cardiac Cath, PTCA's etc)
History & Physical
Follow-up Visits
Discharge Summary
Operative Reports
Pathology Reports
Send all available records
Patient Information
Patient's Name
First
Last
Patient SSN#
Patient Signature
Date
MM slash DD slash YYYY
Consent
Read and agreed on date indicated
This written request for the release of medical records is valid for 12 months from the date of my signature unless revoked in writing by me or my authorized agent. I agree to hold both the sending and receiving parties to this request harmless from any and all costs, liability and damages of any nature resulting or indirectly from the release of my medical records. I understand that the information released may include sensitive information related to behavior and/or mental health, drugs and alcohol(including records of a program that provides alcohol or drug abuse diagnosis, treatment or referral, as defined by federal law at 42 C.F.R part 2), HIV/ AIDS and other communicable diseases, and genetic testing
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