FL RW Portal

Select Service County*

Select Agency

Eligibility Case Manager

Skip if you do not have or know your case manager

First Name *

Middle Name

Last Name*

Date of Birth*

Sex*

ID Number

Information May Be Disclosed By

Person/Facility*

Phone Number*

Address

City*

State*

Zip Code

County Name

Information May Be Disclosed To

Person/Facility*

Phone Number*

Method of Disclosure

At least 1 Method of Disclosure is Required!

Pick up at Clinic/Facility

Fax Number

Fax Number*

Email Address (Please note that emailing may not be a secured method of communication)

Email Address*

Address

City*

State*

Zip

County*

Information To Be Disclosed

At least 1 Information To Be Disclosed is Required!

General Medical Record(s), including STD and TB

Progress Notes

History and Physical Results

Immunizations

Family Planning

Prenatal Records

Consultation

Diagnostic Test Reports(Specifiy Type of test(s))

Specify Test Type

Other

Specify Other*

I Specifically Authorize Release Of Information Relating To

At least 1 choice for information to be Released is Required!

HIV test results for non-treatment purposes

Substance Abuse Service Provider Client Records

Psychiatric, Psychological or Psychotherapeutic note

WIC

Early Intervention

Purpose Of Disclosure

At least 1 choice for Purpose of Disclosure is Required!

Continuity of Care

Personal Use

Other

Specify Other*

Expiration Date: This authorization will expire(insert date or event) I understand that if I fail to specify an expiration date or event, this authorization will expire tweleve (12) months from the date on which it was signed.
Expiration Date should greater than current date
Redisclosure: I undestand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by fedral privacy laws or regulations.
Conditioning: I understand that completing this authorization form is voluntary. I realize that treatment will not be denied if I refuse to sign this form.
Revocation: I understand that I have the right to revoke this authorization anytime. If I revoke this authorization, I understand that I may do so in writing and that I must present my revocation to the medical record department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company, Medicaid and Medicare.

Print Name

Self or Representative's Relationship to Client

If you are a legal representative of the person whose information you are requesting, you must provide documentation providing your legal authority to the request this information (for example, power of attorney, healthcare surrogate form, order, appointment of a guardianship, order appointing personal representative, letters of administration).

Communication:

Email

Click here if you would like to receive email notifications on form updates. Please provide your email address in the field above.

Signature Date

System Support

Authorization to Disclose Confidential Information (DH3203)