Release of Information

Instructions:

1. Download the Release of Information Form.PDF (41 KB)
2. Print it
3. Complete All sections
4. SIGN it
5. Send it to us using one of the two methods below 

Fax completed form to our main office:

(727) 329-5401

Mail completed form to our main office:

PO BOX 76479
St. Petersburg, FL 33734-6479

Please allow 3-5 business days upon receipt of your release in order for us to
process and mail your records.

Due to HIPAA Regulations our practice will not fax out records. We will
only mail requested records to supplied address on form.

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