Medical Record Release Form

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MEDICAL RECORD RELEASE AND HEALTH INFORMATION AUTHORIZATION

Patient / Individual Information

Full Name

First Middle Last

Date of Birth

Phone

Street Address

City

State

Zip Code

1. Authorized Entities
Disclosing Entity (From Whom): Any healthcare provider, physician, clinic, hospital, or medical repository holding the individual's records.

Receiving Entity (To Whom): Avail Health & Behavioral Solutions, LLC
Address: 541 E Tennessee St #110, Tallahassee, FL 32308
Phone: (850) 329-2284
Email: staff@availhbs.com

2. Scope of Disclosure (Select One Option Only)
The individual must initial next to either Option A or Option B to determine the data scope.

OPTION A: FULL DISCLOSURE AUTHORIZATION I authorize the release of ALL my health history and medical records. This includes, but is not limited to: diagnoses, treatment notes, laboratory results, surgical reports, prescription histories, and evaluations. Explicit Consent for Sensitive Data: I specifically authorize the release of information relating to: mental health, substance or alcohol abuse (regulated under 42 CFR Part 2), Human Immunodeficiency Virus (HIV) testing or treatment, and Sexually Transmitted Diseases (STDs).

OPTION B: LIMITED DISCLOSURE AUTHORIZATION I authorize the release of ONLY the specific medical items or timeframes detailed below: Specific Dates of Service:

From

Specific Records Permitted

Restrictions: I do NOT authorize the release of (e.g., genetic tests, mental health):

3. Purpose of Disclosure
Purpose: To facilitate independent contractor vetting, medical physical clearance reviews, clinical placement scheduling, or care coordination services managed by the Avail Health & Behavioral Solutions, LLC.

4. Acknowledgments and HIPAA Compliance Statements
Right to Revoke: I understand I have the right to revoke this authorization in writing at any time. Revocation will not impact data shared prior to processing the written request.
Non-Conditioning: Avail Health & Behavioral Solutions, LLC will not condition my services on whether I sign this authorization.
Redisclosure Notice: Information disclosed pursuant to this form may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules (HIPAA Privacy Rule).
Florida Rebuttable Presumption: This form conforms to Florida Statute § 408.051. A properly completed version creates a legal presumption that the disclosure was appropriate.

5. Expiration
This authorization automatically expires exactly twelve (12) months from the date of signature below unless an alternate date or event is specified here:

6. Signature And Execution
By signing below, I certify that I have read this document and voluntarily approve the data exchange.

Signature of Patient

Date Signed

Time

If signed by a Legal Representative / Personal Representative:

Printed Representative Name

Relationship to Patient

Signature of Representative

Medical Record Release Form

MEDICAL RECORD RELEASE AND HEALTH INFORMATION AUTHORIZATION

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