Julia Barriga MD Tampa FL Form

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Patient Authorization for Use and Disclosure of
Protected Health Information

Patient Name

Birth date

Maiden/previous/other names

This Will Authorize The Following Providers

Provider or Practice Name

Address

Telephone

Fax

To Release Information Selected Below To:

Julia Barriga, M,D.,P.A.5001 E.

5001 East Busch Blvd Tampa, FL 33617 | Phone (813) 984-8846, Fax (813) 984-8827 | DSM: barrigamd@juliabarrigamd.opdirect.net

INFORMATION REGARDING:

All medical records
Ear, Nose, Throat
Neurologic
Ophthalmology
Allergies

Operative reports
Consultations
Specialist Reports
Orthopedic
Other

Mental health records
History and physical
Physical form
X-Ray and Lab Reports
ER Reports

Audiological
Education (IEP)
Treatment plan
Immunizations
Medical Reports from

To

PURPOSE OF RELEASE (CHECK ALL THAT APPLY):

Treatment/Referral

Insurance purposes

Personal use

Change of physician