Standard authorization of use and disclosure of protected Health information

Information to be Used or Disclosed – The information covered by this authorization includes:

Patient’s entire medical history, mental or physical condition, diagnoses, treatment including psychiatric, drug or

alcohol abuse treatment.

Persons Authorized to Use or Disclose Information – Information listed above will be used or disclosed by:

Physicians and Personnel of Florida Medical Pain Management

Persons to Whom Information May be Disclosed:

Please list anyone that Florida Pain Management will be able to release medical information to regarding your care:

1. My referring physician 4. Spouse

2. My primary care physician 5.

3. Mental health care provider 6.

Expiration date of Authorization

This authorization is effective indefinitely unless revoked or terminated by the patient or the patient’s personal


Right to Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to Florida Medical Pain Management.

You should contact the Florida Medical Pain Management Compliance Officer to terminate this authorization.

Potential for Re-disclosure

Information that is disclosed under this authorization may be disclosed again by the person or organization to which it was

sent. The privacy of this information may not be protected under the federal privacy regulations.

Overall, by signing this form you are giving Florida Medical Pain Management permission to release or receive your

medical records to or from any physician office, hospital, attorney, or any persons name from above you approved us to

disclose information to. Your signature confirms that you have received a Notice of Privacy Practices.