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Hughes Direct Primary Care, LLCAuthorization to Release Protected Health InformationName of Patient: Street Address: City: State: Zip: Phone: DOB: SS#: Release To: Douglas Hughes, D.O. - Hughes Direct Primary Care Street Address  Corkscrew Road Suite 101Estero, FL Street Address
Office: PHONE NUMBER AVAILABLEFax: PHONE NUMBER AVAILABLERelease From: _ Release Reason:Continuing Medical Care Transfer to Another ProviderClaim for Reimbursement LegalOtherSpecified information or dates of treatment to be released: ALLFace Sheet Emergency Room Reports History & PhysicalOperative Reports Laboratory Reports Discharge SummaryPathology Reports X-Ray Reports Clinical NotesOther (Please Specify): ALLAuthorization:I understand that the information disclosed may contain testing or treatment information in relation to Mental Health; Drug and/or Alcohol Abuse Treatment; Sexually Transmitted Diseases; HIV/AIDS Virus I understand that once the information is disclosed, this information is subject to redisclosure and may no longer be protected by the federal privacy regulation.I understand that this form may be revoked at any time providing the information has not already been disclosed. I may revoke this authorization at any time by notifying Hughes Direct Primary Care, LLC in writing. I understand that refusal to sign this authorization does not condition treatment. I understand that this authorization will expire 1 year from the date signed unless otherwise specified. Date, event, or condition on which authorization will expire if other than 1 year: Signature of Patient: Date: Signature of Other Authorized Person*: Date: Relationship to Patient/Authority to Act for Patient:*Authorization must be signed by the parent or legal guardian of any patient under 18; the legal guardian of any patient under guardianship; the personal representative of a deceased patient, or if no personal representative, the spouse, any adult child of a deceased patient. If a patient is under 18, records are protected by Federal Law regarding drug and alcohol abuse, authorization must be signed by both patient and parent or legal guardian. Updated 8/18/23