Authorization for Release of Information□ Urgent Care Center 315 75th St. W., Bradenton, FL 34209 P: 941-761-1616 F: 855-876-6218□ Imaging Center 315 75th St. W., Bradenton, FL 34209 P: 941-761-8828 F: 941-761-9527□ Internal Medicine 315 75th St. W„ Bradenton, FL 34209 P: 941-792-2211 F: 855-622-2362□ General Surgery 315 75th St. W., Bradenton, FL 34209 P: 941-795-3600 F: 855-521-2857□ Rheumatology 315 75th St. W., Bradenton, FL 34209 P: 941-792-8329 F: 855-521-2857□ Neurology & Neurosurgery 7005 Cortez Rd. W., Bradenton, FL 34210 P: 941-750-0602 F: 855-637-3923□ Cortez Road Family Medicine 7005 Cortez Rd. W., Bradenton, FL 34210 P: 941-792-2122 F: 855-637-3920□ Continuity Clinic Blake Primary Care 7005 Cortez Rd. W., Bradenton, FL 34210 P: 941-752-2882 F: 844-251-9590□ Bayshore Family Medicine 6033 26th St. W., Bradenton, FL 34207 P: 941-752-2025 F: 855-817-7456□ Physical Therapy & Physiatry 4110 Manatee Ave. W., Bradenton, FL 34205 P: 941-748-8383 F: 855-423-5096

□ REQUEST INFORMATIONI Hereby Authorize Pinnacle Medical Group’s______________________(Select from above) to REQUEST information FROM:Doctor/Facility Name and Address:________________________________________________________________________

Phone #:______________________________________________ Fax #:______________________________________

□ RELEASE INFORMATIONI Hereby Authorize Pinnacle Medical Group’s______________________(Select from above) to RELEASE information TO:Doctor/Facility Name and Address:________________________________________________________________________

Phone #:______________________________________________ Fax #:______________________________________

REGARDING THE FOLLOWING PATIENT:Name:____________________________________________________________________Phone #:___________________Address:_______________________________________________________________Date of Birth:___________________

Records to be Released:Date(s) treatment was received:___________________________________________□ Consultative Report □ History and Physical □ Laboratory Report□ Operative Report □ Pathology Report □ Progress Notes□ X-Ray Film □ X-Ray □ Report Photographs, Videos Digital or Other Images□ Entire Record □ Certified Copy □ Other____________________________________

I authorize the release of information relating to:□ HIV/AIDS Testing/Treatment □ Psychiatric Evaluation/Treatment □ Alcohol/Drug Abuse Evaluation/Treatment

Purpose of Release:□ Continuing care for ongoing treatment □ Transfer of Care □ Other________________________________________

This authorization expires on the following date, event or condition:__________________________________________.If I do not specify any expiration date, event or condition, this authorization will expire in one year.

Statement of Authorization:• I understand that, except for research-related treatment, Pinnacle Medical Group will not condition my treatment, payment,

enrollment, or eligibility for benefits on my signing this authorization.• Except to the extent that action has already been taken, I understand that I may revoke this authorization at any time by

giving written notification to Pinnacle Medical Group (Medical Records). A photocopy/fax of this authorization will be treated in the same manner as the original.

• I do not authorize further release to any third party. I understand that once information is released as specified in this authorization, the facility, their employees and my physician(s) cannot prevent the re-disclosure of that information. I hereby release each of them from any and all liability arising directly or indirectly from disclosure authorized by this consent and any re-disclosure of that information.

Signature of Patient/Legally Authorized Representative Date

Relationship to Patient Reason Patient Unable to Sign