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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.This authorization is voluntary and is not a condition of enrollment in a health plan, eligibility for benefits or payment of claims. This HIPAA release form Florida enables patients to permit any person or third parties to have access to private health records. Complete the first page of this form and return it to: HIPAA Privacy Officer, Agency for Health Care Administration, 2727. Purpose: The purpose of this authorization is to permit Medicare to release to a third party, such as someone other than the. 1232G), also known as the Buckley Amendment, and Section 228. Authorization for Release of Medical Records and Personal Health Information. Enrollment and Authorization for e-Services. To obtain a copy of your EMS report, please complete the Authorization For Release of Medical Information form.