Authorization for Release of Medical Information
Obtain From:
Name: Full Circle Women's Care
Address: 6600 Charing St, Jacksonville, FL 32216
Phone: (904) 674-0022
Fax: (844) 656-2483
Information to Be Released (Please select Yes or No for each category listed):
* * * * * * * * * * * * * * * * * * * * * * * * *
I understand that these records are of a privileged and confidential status. I waive that status for the purpose
contained within this authorization. I agree to hold Full Circle Women's Care harmless from any and all cost,
liability, and damages of any nature whatsoever, including attorney fees resulting directly or indirectly from Full
Circle Women's Care's release of these records pursuant to this consent. This authorization will automatically expire
(90) days following the date of signature without my expressed revocation.
I also understand that a copying fee applies to hard-copy records: $1.00 per page for the first 20 pages,
and $0.25 per page for each page beyond that.
I acknowledge that I have read and understand this authorization and its content.
Signature of Patient (must be 18 yrs +)
Prohibition of re-disclosure. The information is being disclosed to you from records whose
confidentiality is protected by state law. Specifically Florida Statutes 395.3025, 455.667 and 394.459. State Laws
prohibit you from any further disclosure of this data without the specific written consent of the person to whom it
pertains, or as otherwise permitted by Florida state statutes and regulations. A general authorization is not
sufficient for this purpose.
⚠ To be completed by Full Circle Women's Care Staff Only
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