Authorization to Disclose Confidential Information

To request records be sent by the Florida Department of Health in Charlotte County

- Fill out and sign the Authorization to Disclose Confidential Information DH 3203 Disclosed by FDOH. (a separate form is required for each patient)

- Return the completed form along with your current government issued photo-id.

- Please include your contact information should we have any questions.

Email, fax, or mail the documents.

Subject: Medical Records

- We encourage you to mark the email as confidential.

Note: Florida has a very broad public records law.

Most written communications to or from state officials regarding state business are public records available to the public and media upon request.

Your email communication may therefore be subject to public disclosure.

Fax: 941-624-7202

Mail: Florida Department of Health in Charlotte County

Attention: Medical Records

1100 Loveland Blvd

Port Charlotte, Florida 33980

To send records to the Florida Department of Health in Charlotte County.

-Fill out and sign the Authorization to Disclose Confidential Information DH 3203 Disclosed to FDOH. (a separate form is required for each patient)

-Contact company/person releasing confidential information for their specific requirements.

Any questions please call 941-624-7200 extension 7298