Authorization to Disclose Medical Records - ENGLISH Logo
  • ROSABEL M BENCOMO M.D P.A

    6840 SW 40th Street, Suite 209, Miami, FL 33155

    Toll Free: (877) 479-1479 | Office: (786) 222-8807 | Fax: (305) 763-8379

  • Authorization to Disclose Medical Records

    **(Required by the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 and 164)**
  • This form is to provide Rosabel M Bencomo MD PA staff / MDteleMe staff with a means to request the use and/or disclosure of an individual's protected health information.

  • By signing this form, I authorize the release of health information, including Protected Health Information.

  • INFORMATION MAY BE DISCLOSED BY: Rosabel M Bencomo MD PA / MDteleMe and any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf.
    I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. If it does include this information, I specifically authorize release of that information to the person(s) listed above.



  • REDISCLOSURE: I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.
    CONDITIONING: I understand that completing this authorization form is voluntary and that treatment, payment, enrollment, or eligibility for benefits cannot be conditioned on whether I sign this authorization.
    REVOCATION: I understand that I have the right to revoke this authorization any time. If I revoke this authorization, I understand that I must do so in writing and that I must present my revocation to the medical record department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company, Medicaid and Medicare.
    I request and authorize the disclosure of information described above.

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