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941-365-1321 | PATIENT PORTAL
Concierge Medical Services
  • Home
  • About
    • Dr. Bart Price
    • Dr. Petra Travnicek
    • CMS Staff
  • Our Program
    • FAQs
  • Patient Forms
    • New Patient Package
    • Medical Records Release
    • Membership Agreement
    • Annual Exam
    • COVID-19 Informed Consent
  • Contact
  • Patient Portal

Release Medical Information

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  • Records Authorized to be Released

  • • I am not required to sign this authorization and that my health care or payment for care will not be affected by my refusal. • Federal privacy regulations will no longer apply to the information disclosed, and that may redisclose the information. • I am entitled to receive a copy of this authorization. • A copy of this authorization may be utilized with the same effectiveness as an original.

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1250 S Tamiami Trail

Suite 301

Sarasota, FL 34239

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