Please list all physician(s) names and fax numbers that records are to be release from:
Lighthouse Pediatrics of Naples
3227 Horshooe Drive South, Naples, FL 34104
Ph: (239) 449-9882
Fx: (239) 449-9884
I understand that the release or transfer of the information specified to any person or entity not specified above is prohibited. An additional written consent must be completed for any proposed new use of the information or for its transfer to another person. I release and hold harmless Lighthouse Pediatrics of Naples and the physicians of the medical practice from all liability that may arise from complying with this authorization.
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