Medical Release Form

    I hereby authorize use or disclosure of protected health information about me as described below.

    1. The following specific person/class of person/facility is authorized to use or disclose information about me.

    2. The following person (or class of persons) may receive disclosure of protected health information about me:

    Brian Thornburg DO PA
    5500 Bryson Drive, Suite 301,
    Naples, Florida 34109

    By EmailBy Fax

    (239.348.7391) Please Fax One Chart At A Time

    The specific that should be disclosed:

    All Records


    3. Brian Thornburg DO PA takes all necessary steps to ensure and protect our patient's private health information.

    4. I may revoke this authorization by notifying Brian Thornburg DO PA in writing of my desire to revoke it. However, I understand that any action already taken in reliance to this authorization cannot be reversed, and my revocation will not affect those actions.

    5. My purpose/use of this information is for:

    Transfer Of CareSpecialistPersonalOther

    6. This authorization expires 90 days from signature date.

    FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copying of patient records.

    Members are entitled to one set free of charge. THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING. A photocopy/fax of this authorization will be treated in the same way as an original. Brian Thornburg DO PA health records may include records that it received from other organizations. If these records have been used by Brian Thornburg DO PA and filed in the record Brian Thornburg DO PA maintains about you, these records may be released with your Brian Thornburg DO PA records. Brian Thornburg DO PA cannot prevent re disclosure of your information by the person or organization who receives your records under this authorization. and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization. you release Brian Thornburg DO PA from any and all liability resulting from a re disclosure by the recipient. Your signature indicates that you have read and understand this form. and authorize release your information as described above.

    Date Of Signature: