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Patient Forms · Privacy & records

Authorization to Release or Request Medical Records

Use this form to send your records to another doctor or person, to have another provider send your records to us, or to get a copy for yourself — about 6 minutes.

Send it online when you finish, or print it and bring it to your visit. What you send goes securely to our office’s patient system. Nothing is sent until you press Send, and nothing you type is saved on this device.

Start Print a blank copy (opens in a new tab)

Urological Consultants of Florida
12411 Biscayne Boulevard, North Miami, FL 33181 · (305) 672-4222 · www.miamiurologyconsultants.com

Authorization to Release or Request Medical RecordsROI-1 · v2026.11.1

Authorization to Release or Request Medical Records

About 6 minutes · ROI-1 · v2026.11.1

All fields are required unless marked (optional).

About the patient

MM/DD/YYYY

For example a maiden name, so the other office can find your records.

What would you like us to do?
Choose one
The other provider, person or organization
Information to be released
Check everything that should be included
Dates of service

MM/DD/YYYY

MM/DD/YYYY

Specially protected information

Florida and federal law give these records extra protection. They are NOT included — even if you checked “entire medical record” — unless you check the box AND write your initials beside it. These boxes apply to records we send.

Purpose, expiration and delivery
Purpose of the release
This authorization ends

MM/DD/YYYY

For example: when my records have been sent once; at the end of my legal case.

How should the records be delivered?
Please read before signing

YOUR RIGHTS UNDER THIS AUTHORIZATION

I authorize the use and disclosure of my health information as described on this form.

I may cancel (revoke) this authorization at any time by calling the office at (305) 672-4222, by emailing our Privacy Officer at [email protected] or the staff member I work with, or by letter to the office. A cancellation must be in writing; an email counts as written notice. Cancelling does not affect anything already done in reliance on this authorization.

Urological Consultants of Florida will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this authorization.

Information disclosed under this authorization may be redisclosed by the person or organization that receives it and may no longer be protected by federal privacy law.

Copy fees, if any, follow Florida law.

I am entitled to a copy of this signed authorization.

Signature
Who is signing?

For example: parent of a minor; court-appointed guardian; health care surrogate; power of attorney. Please bring a copy of the document that gives you authority.

Signature of patient or personal representative

Review and send

When you have finished, send your answers to our office. Nothing is sent until you press Send to the practice. You can also print your form and bring it instead.

Sent securely to our office’s patient system. This page does not save what you type on this device.

What to bring to your visit

  • Photo ID
  • Your insurance card(s)
  • Your medication list or bottles
  • Any referral or recent records, if you have them

Questions? Call (305) 672-4222, Monday–Friday, 9:00 am – 5:00 pm.