Medical Records

813-778-0406

Click Here to Download Medical Records Request Form Submit Your Medical Records Request Online

Medical Records Request Form

Patient Request: $6.50 flat fee for electronic access or $0.12 per page for paper copies mailed
Last Name*
First Name*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address City/state ZIP Code
Phone Number*
Reason for requesting records:
- Continuation of Care/Transfer of Care
- Dissatisfaction With Provider
- Attorney/Legal
- Insurance Company
- Workman’s Compensation
- Patient Personal Use
- Other (specify):
Other*
I authorize Florida Medical Clinic, LLC to share the health information listed below to the following person, group, or entity
Entity 1*
Name 1*
Fax #/Mailing Address 1/Email*
Entity 2
Name 2
Fax #/Mailing Address 2/Email
Please select the type of information to be used or disclosed (include dates where appropriate)
- Laboratory Results
Lab Results Date Range - Start
MM slash DD slash YYYY
Lab Results Date Range - End
MM slash DD slash YYYY
- X-Ray and Imaging Reports
X-Ray Date Range - Start
MM slash DD slash YYYY
X-Ray Date Range - End
MM slash DD slash YYYY
Type of Information
- Entire Record
- Medication List
- List of Allergies
- Immunization Records
- Records from Non-FMC Providers
- Most Recent History and Physical
- Other (specify):
Other*
Encounter 1
Date Range - Start
MM slash DD slash YYYY
Date Range - End
MM slash DD slash YYYY
Encounter 2
Date Range - Start
MM slash DD slash YYYY
Date Range - End
MM slash DD slash YYYY
Encounter 3
Date Range - Start
MM slash DD slash YYYY
Date Range - End
MM slash DD slash YYYY
I authorize Florida Medical Clinic, LLC to also share the following to the entity listed above. By not selecting any of the options below, I understand this information will not be shared.
- Treatment for Alcohol or Drug use/abuse
- Mental Health information (excluding psychotherapy)
- Sexually Transmitted Diseases/HIV-Related Information
- Psychotherapy
- Genetic
- Communicable diseases (Hepatitis A, B, C)
- Other (specify):
Other*
This authorization for release of information covers the period of healthcare services rendered from:*
- Date Range
- All past, present, and future periods
Date Range - Start*
MM slash DD slash YYYY
Date Range - End*
MM slash DD slash YYYY
Unless otherwise revoked, this authorization will expire on the following date, event, or condition. If no date is specified, I understand this authorization will expire one year from the date below.*
- Expiration Date
- Automatic expiration after one year
Expiration Date*
MM slash DD slash YYYY
I understand the information in my health record may include information relating to sexually transmitted disease and other reportable disease, AIDS/HIV. It may also include psychiatric or mental health services, and treatment for alcohol and drug abuse. By not selecting any of these options above, I understand sexually transmitted diseases, mental health, and drug abuse will not be disclosed.

I have the right to revoke this authorization at any time by contacting Florida Medical Clinic, LLC. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

I understand signing this authorization is voluntary. I do not need to sign this form in order to receive treatment.

I understand I may inspect or copy this information to be used or disclosed, as provided in CFR 164.524.

I understand that any disclosure of information carries with the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.

I understand there is a fee for obtaining medical records and I agree to pay for such charges.

If I have any questions about disclosure of my health information I can contact Florida Medical Clinic’s Privacy Officer at (813)751-3603.
Electronic Signature*
Signature Date
MM slash DD slash YYYY
Security Questions
Who was the last provider you saw? If the last provider you saw is not listed, please select "Other".*
Provider's Name

Please provide the name of the last doctor you saw here if you did not see it in the dropdown above.
What is your Driver’s License Number?*
No License
- I don't have a license
Form Completed & Signed By
- Patient
- Guardian
- Healthcare proxy/surrogate
- Personal Representative
- Employee (FMC use ONLY)
Employee Name*

User Privacy Rights

(Patient Request ONLY)

You may request your records by:

1. Completing the form electronically
2. Mailing the form to Florida Medical Clinic Medical Records Department 2150 Via Bella Blvd. Land O Lakes FL 34639
3. Faxing the form to 813.355.5896
4. Emailing the form to HPROI@floridamedicalclinic.com
5. In-person at your doctor’s office
6. Fill out and submit form below

If you have questions, please call our medical records department at 813.778.0406

Questions About Medical Records

Is there a charge for receiving copies of my medical record?

Yes, you may receive copies of your medical records either electronically or by mail.
Electronic access $6.50 flat fee
Mail $0.12 per page for paper copies including postage and tax
You can save money by asking for specific documents such as most recent lab results rather than the entire record. Some medical offices may charge a nominal copying fee.

How can I obtain a copy of my medical record?

Forms are available in each of our medical offices or you may send a request to our Medical Records Department.
Mail: Florida Medical Clinic Medical Records Department 2150 Via Bella Blvd. Land O Lakes FL 34639
Fax: 813.355.5896
Email: HPROI@floridamedicalclinic.com

Your request must include the following:

Patient’s full name
Date of birth
Last 4 digits of patient’s social security number
Patient’s telephone number
Name, address and telephone number where the records are to be sent
Specific items or dates of service needed
Any restrictions on the request
Date of the request
Signature of the patient or, if the patient is a child, the parent or guardian signature
Date this authorization expires
If signed by a personal representative, a description of his/her authority to act for the individual and a copy of the document giving that authority

How long will it take to get copies of my medical records?

All medical records generally are received within 14 days; however, it may take up to 30 days to receive your records based on the methodology you select (e.g., mailing versus email).

Can I get copies of my diagnostic images (e.g., mammogram, CT, MRI)?

Yes, please complete the medical records request form above and indicate you would like copies of your diagnostic images.

How can I obtain my Behavior Health Records?

Complete the medical records request form above and let us know the name of the department or provider(s) you would like your Behavioral Health records from.

I requested copies of my medical records, but I haven’t received them, what should I do?

To check the status of your medical records request please call or email Florida Medical Clinic’s Medical Records department.
Phone: 813.778.0406
Email: HPROI@floridamedicalclinic.com

How can one of my outside doctors get copies of my medical records?

Another healthcare provider (for example, a physician, nurse practitioner, or physical therapist), who is treating you can request copies of your health information at any time. It may be necessary to verify that this provider is currently treating you. The healthcare provider should submit a request in writing.

How can I send my records to a third-party (e.g., attorney, Social Security Office, Life Insurance, etc.)?

You must complete an authorization form (see form above) and include the third party’s name, address or phone, methodology to send the records.

Are medical records confidential?

The information found in medical records is confidential. Patients confide in their physicians because they are assured of this confidentiality and might not share the necessary personal information if this privilege did not exist. Healthcare workers are mandated by law and by professional standards to protect patient confidentiality. There are also state and federal laws to protect information related to specific diagnoses such as psychiatric/psychological, treatment of substance abuse (drugs and alcohol), and AIDS/HIV.

There is some incorrect information on my medical record. How can I get it corrected?

You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “No” to your request but we’ll tell you why in writing within 60 days. Please call our Privacy Officer at 352.567.0188 for more information.

Can I receive my medical records on a flash drive or CD?

No, Florida Medical Clinic records are not available in these formats at this time. However, for your convenience, we can deliver them to you electronically. Please provide an email address on your authorization form and once the records are prepared, we will email you a link that you can use to access your records.

Can I review my medical record in person?

You may review your medical record by appointment only with your health care provider or Privacy Officer.

Is an Authorization for Release of Information “good” forever?

Valid authorizations are good until revoked or they expire. It is important to note that once a release request has been fulfilled and additional records are requested, a new release form must be completed.

Who can access my medical record?

We are required by law to maintain the privacy and security of your medical record. We will not use or share your information, other than as described in our Notice of Privacy Practices (NPP), unless you tell us we can, and you may change your mind at any time.

How secure are computerized medical records?

Computer-based medical records are as safe as paper records and are covered by the same laws. There are technical safeguards for the protection of computerized data as well as procedures for identifying and punishing violators.

How long will you keep my medical record?

By Florida Law, medical records must be retained for a minimum of five years. Most records are retained longer.

What can I do if I suspect that someone is looking at my medical record without permission?

You should report this to the Privacy Officer appointed by Florida Medical Clinic at 352.567.0188

My son is a 19-year old college student. My insurance pays for his medical bills and I claim him as a dependent on my income tax. Why can’t I see his medical records?

By law, only the adult (age 18 or older) patient or a legally designated representative has the authority to release the information contained in a medical records about him/herself, regardless of who is paying the bills. Legally designated representatives include court-appointed guardians or others with power of attorney for the patient. For children under age 18, only a parent or a court-appointed guardian may authorize release of medical information.

My family member died last year, can I request a copy of her medical records?

The next of kin or personal representative of the estate may request those records. It may be necessary to verify that the patient has actually died and the identity of the next of kin.

My spouse and I are divorced. Can we both have access to our children’s medical records?

Yes, unless parental rights have been severed by the court.

Medical Records Consent

Your record is the physical property of Florida Medical Clinic, LLC. However, the patient controls the release of the information contained in the record. In general, you must give permission for anyone, other than a member of your healthcare team, to have access to your medical record. By law, your records may be disclosed without your permission under certain circumstances such as in response to a subpoena or court order, to certain government and regulatory bodies, to someone who holds your power of attorney, to someone you have designated as your healthcare surrogate, to another healthcare provider for continued care, and to your healthcare insurer to obtain reimbursement for your care.

By law, only the adult (age 18 or older) patient or a legally designated representative has the authority to release the information contained in a medical record about them, regardless of who is paying the bills. Legally designated representatives include court-appointed guardians or others with power of attorney for the patient. For children under age 18, only a parent or court-appointed guardian may authorize release of medical information. The next of kin or personal representative of the estate may request those records.

For medical records questions:
813.778.0406
HPROI@floridamedicalclinic.com

For privacy or security questions:
813.751.3603

Medical Records Request