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Dear Physician / Medical Facility:  ______________________________________________

Physician Telephone:  _________________________  Fax: _________________________


I hereby authorize you, and request of you to forward to the Norman Parathyroid Center my pertinent medical records. I am giving my consent to the release and disclosure of my personal health information to:

Norman Parathyroid Center
2400 Cypress Glen Drive
Wesley Chapel, FL 33544

James Norman, MD, FACS, FACE
Douglas Politz, MD, FACS, FACE
Jose Lopez, MD, FACS
Deva Boone, MD, FACS, FACE
Daniel Ruan, MD, FACS
Jamie Mitchell, MD, FACS
Kevin Parrack, MD, FACS


Please FAX the following records to: Fax: 813-444-5598

  • All lab reports
  • Progress notes pertaining to high calcium / parathyroid issues
  • Recent bone density tests (DEXA scans)
  • All biopsy/pathology reports
  • Results from any parathyroid scans (sestamibi, CT scan, or thyroid ultrasound)
  • Any records pertaining to neck surgery, thyroid/parathyroid issues

Patient Name  ________________________________________________________

Address  ____________________________________________________________

City  _________________________ State __________________ Zip ____________

Date of Birth  ______ / _____ / _______       

Patient Signature:  ______________________________________ Date:  __________


HIPAA Compliance Notification:

  • This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
  • I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
  • I understand that the disclosed information may, unless expressly limited by me in writing, include information relating to acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection, treatment for drug or alcohol abuse, and/or mental or behavior health or psychiatric care.
  • I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
  • I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
  • ________________________________________