PatientWho is your Concierge Medical Physician?Bart Price, MDPetra Travnicek, MD, FACPName of Patient First Middle Last I authorize the named health care provider to release the information or records specified to the above referenced physician, 1250 S Tamiami Trail, Suite 301, Sarasota, FL 34239. 941-365-1321/Fax 941-365-4071 upon request in person or by mail to the address specified at the time of the request.HiddenRECORDS AUTHORIZED TO BE RELEASED:HiddenProvider Name HiddenProvider Address HiddenProvider PhoneHiddenProvider FaxHiddenPatient Name HiddenPatient DOB MM slash DD slash YYYY HiddenRecords to be Released Admission history and physical Discharge summary Mammogram Office notes Outpatient records Immunization records Lab reports Radiological reports Consultation notes or reports Bone density report Colonoscopy with pathology Other ____ Admission history and physical ____ Lab reports ____ Discharge summary ____ Radiological reports ____ Mammogram ____ Consultation notes or reports ____ Office notes ____ Bone density report ____ Outpatient records ____ Colonoscopy with pathology ____ Immunization records ____ Other HiddenOTHER (specify) HiddenExtent or nature of records to be released: (example, specific hospitalization or visit)Authorization• The office will contact all prior and/ or current physicians to obtain your medical records. • 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. I understand that I can revoke this authorization at any time by writing to the health care provider, but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received. This authorization will expire one year from the date of the signature below. This information will be used for the purpose of Continuity of Care.Name of Patient or Representative Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Patient DOB MM slash DD slash YYYY Relationship to Patient Patient or Representative SignatureDate Month Day Year EmailThis field is for validation purposes and should be left unchanged.
