I hereby authorize;

Régie des Rentes du Québec
 P. O. Box 5200 Québec (Québec) G1K 7S9
 PATIENT:   SERGE MOREL   

to release a copy of all my patient records since 1992 containing protected health information to:

This authorization is given pursuant to Florida Statute 456.057 and HIPAA regulations. I understand that Florida Statute 456.057(10) makes clear that any third party to whom records are disclosed is prohibited from further disclosing any information in the medical record without the expressed written consent of the patient or the patient's legal representatives.

Patient's or Patient's Legal Representative's Signature

Patient's Date of Birth:___________________________________

Date Signed:___________________________________________

Specific description of information to be disclosed:

Kindly forward all documentation to my attention as soon as possible.

HIPAA compliant