Release Medical Information

    Patient Information:

    Parent/Legal Guardian Information:

    I hereby authorize the release of my child’s medical information as described below:

    Release From:

    • Provider/Facility Name: Pediatric Pulmonary Specialists

    • Address: 4714 N Armenia Ave Suite 201 Tampa FL 33603

    • Phone/Fax: 813-870-1995 / 813-875-1889

    Release To:

    Information to be Released (Check all that apply):

    Purpose of Release (Check all that apply):

    Authorization Terms:

    I understand that:
    • I may revoke this authorization in writing at any time.
    • Revocation does not apply to information already released under this authorization.
    • This authorization expires one year from the date signed unless otherwise specified:
    Expiration Date (optional):
    • Information disclosed may no longer be protected by HIPAA once released to the recipient.