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Florida Perinatal Center, LLC.
Maternal Fetal Medicine
Christine F. Edwards, M.D., FACOG
Laura Laffineuse, M.D., FACOG

 

9750 N.W. 33rd Street, Suite 120
Coral Springs, FL 33065
T:954-255-5799

9325 W. Glades Road, Suite 206
Boca Raton, FL 33434
T: 561-488-5015

Fax: 954-255-1989

Record Release


I understand that, under Florida Law, the classification of records checked above relating to treatment rendered to me are privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an expressed and informed consent. In addition, I understand that those records will not be released to persons and agencies other than those designated by me or my personal representative or otherwise provided by Florida law.


Patient Name:





Address:







I,
, authorize




Address:

For the Purpose of:

I authorize release of information covering treatment dates of:

The type and amount of information to be disclosed is a follows (include dates where appropriate):

Entire Medical Record, excluding:

Consultations

Physician Progress Notes

Laboratory Reports

Ultrasound Reports

Other, describe

Yes

Yes

Yes

Yes

Unless otherwise revoked, this authorization will expire six months from the date of the signature listed below.