Authorization for Release of Information
Coastal Anesthesia, P.A.
Michael P. Ederer, D.O.		Julie Morton A.R.N.P.
Telephone 850-279-4417 Fax 850-279-4212

Patient Name: ____________________________________________________________ DOB: ______________________________

Address: ____________________________________________________________________________________________________

City/ State/ Zip: __________________________________________________________ Phone: ______________________________

I authorize the release of medical information as indicated below:
FROM:								TO:
Practice Name: ___________________________________________   	Coastal Anesthesia, P.A.
Michael Ederer D.O. / Julie Morton A.R.N.P.
Fax Number: _____________________________________________		1001 W. College Blvd, STE H, Niceville, FL 32578

____ I would like my records faxed to Coastal Anesthesia at 850-279-4212
____ I would like to pick up my records: please call me at _______________________________________________.
____ I would like my record mailed (please indicate address above)

What to release: Please choose the records you would like released:
____ Outpatient Notes (last 3 visits) 				____ Lab Results
____ MRI and/or X-Ray reports 				____All Medical Records
____ Other: Specify ________________________________________________________________________

Note: The records listed below have special protection by laws. I authorize the release of information pertaining to:
The diagnosis or treatment of AIDS, including results of HIV tests. 		____ YES 		____ NO/ NA
The diagnosis or treatment of drug and/or alcohol abuse. 			____ YES		____ NO/ NA
The treatment and/or consultation for mental health or psychiatric disorders. 	____ YES 		____ NO/ NA

Purpose of the release: Please indicate the reason for this release:
____ For another doctor 			____ To obtain disability 		____ Use in a lawsuit
____ Worker's Comp 			____ Armed forces requirement 	____ Follow Up related to an injury
____ Personal use 				____ Other _________________________________________

Expiration Date: This authorization will expire in sixty days (60) unless otherwise indicated below:
____ Please change the expiration date to last for ______ days.

I understand this authorization can be revoked at any time according to practice's privacy practices. This request must be made in writing and sent to the same place as the original request. Attach a copy of this release if possible. Treatment, payment, enrollment in any health plan is not conditioned on signing this authorization.
Once these records are released, the information is not protected by Coastal Anesthesia, P.A. And may potentially be re-disclosed by the party who received these records. Coastal Anesthesia, P.A., its employees and officers, and attending physicians are released for legal responsibility or liability for release of the above information to the extent indicated and authorized.
I have read and understand this information. I have received a copy of this form and I am the patient or am authorized to act on behalf of the patient to sign this document verifying authorization for the use or disclosure of the protected health information under the above stated terms.

________________________________________________________________________ 	_____________________________________
Signature of Patient or Legal Representative and relationship				Date

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Signature of witness 								Date