To request a copy of your medical record please complete the Authorization to Use and Disclose Protected Health Information form below.

Please make sure the form below is completely filled out, signed, dated and witnessed. 

Authorization to Use and Disclose Protected Health Information

To fax form: 813.239.8397

To mail: 2815 E. Henry Avenue, Suite D-7, Tampa, FL  33610

For more information or questions, please call our Medical Records Department 813.239.8279