Westwood Cardiology Associates, P.A.
AUTHORIZATION FORM FOR PATIENT RECORDS RELEASE (Please Print)

Patient Name: _________________________________ Date of Birth: ___________
                      (Last, First, Middle)

Person/organizations authorized to use or disclose my information:
___________________________
___________________________
___________________________
___________________________
Person/organizations who may receive my information:
___________________________
___________________________
___________________________
___________________________

Specific description of the information to be used or disclosed (including dates):
____________________________________________________________________
____________________________________________________________________

Describe each purpose of the use/disclosure of my health information:
____________________________________________________________________
____________________________________________________________________

Section B: The patient or patient's representative must read and initial the following statements:
  1. I understand that this authorization will expire on
    (Insert date or event) ________________ Initials _______
  2. I understand that I may refuse to sign this form and that my health care and the payment for my health care will not be affected if I do not sign. Initials _______
  3. I understand that I will get a copy of this form after I sign it. Initials _______
  4. I understand that I may revoke this authorization at any time by notifying the Practice in writing, but if I do, the revocation will not have any effect on action already
    taken on this authorization. Initials _______
__________________________________     ________________________
Signature of Patient/Representative            Date

If this authorization is signed by a patient's representative, please complete the following:
Printed name of patient's representative: ______________________________________
Relationship of representative to the patient: ______________________________________
Describe the representative's authority to act for this patient:
________________________________________________________
________________________________________________________
________________________________________________________

*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*