Treatment Center

Medical Release of Records

Medical Records Release

  • Patient

  • Recipient:
    I authorize my health care information and records held by the above named Provider to be released to the following Recipient:

    Miami Stem Cell Treatment Center
    777 So. Flagler Drive
    Suite 800
    West Palm Beach, FL 33401
    By Fax: (561) 756-8772
    By Scan / PDF:


    Information to be disclosed:
    I authorize the release of the following health information:


    MOST RECENT X-Ray Reports
    MOST RECENT Lab Reports
    MOST RECENT CT Scan Report
    MOST RECENT Office Notes
    MOST RECENT Consultation Notes / Reports
    Hospital History & Physical
    Pathology Reports
    Hospital Discharge Summary
    Operative Reports
    Actual Radiologic Images
  • I hereby voluntarily consent to authorize my health care Provider named above to use or disclose my health information during the term of this Authorization to the Recipient that I have identified. I also understand that:

    • Voluntary: I am not required to sign this Authorization; my signature upon it is completely voluntary.
    • Purpose: My health information is being released for the specific purpose of Continuity of Medical Care and Physician Consultation.
    • Revocation: I can revoke this Authorization at any time in writing.
    • Copy: I am entitled to receive a copy of this Authorization.
    • Copy as Original: A copy of this authorization may be utilized with the same legal effect as an original.
    • Term: The Term of this Authorization is for one (1) year following the date of Execution of the Authorization.
    • Inapplicability: This Authorization does not extend to HIV test results, outpatient psychotherapy notes, drug or alcohol treatment records that are protected by federal law, or mental health records that are protected by the Lanterman-Petris-Short Act.
    • Re-disclosure: Information disclosed pursuant to this Authorization may be subject to re-disclosure by the party who receives it because it may no longer be protected by the federal privacy laws.
    • Electronic Medical Records: Records in electronic form can be distributed widely with relative ease and losses or unintended releases of the requested information may occur under circumstances beyond the control of the Provider or Recipient.

  • Use your mouse or touch screen feature to sign in the space provided.
  • If Individual is unable to sign this Authorization, please complete the information below:
Dr. Thomas A. Gionis, MD JD
Stem Cell Research and Treatment