Authorization for Release of Medical Information

Please note: This form must be filled out in its entirety to be valid.

I, the undersigned, do hereby authorize you to release the medical record of:

Name:

Date of Birth:

SS#:

From:

To:

Release to this Fax Number:

Information to be Released

(Reports may include information about drug/alcohol, psychological or communicable diseases including HIV Status)

Office Notes, Correspondence

Lab, X-Ray and other test reports

Requested reports, narratives, forms

May verbally communicate any medical information requested

Records from all dates will be released unless otherwise notes here:

Reason for Release

(Required by Texas)

Release to another physician

Information requested by an insurance carrier

Disability Claim

Self - For Patient's Own Records

Other reason for release:

I understand that I may revoke this consent at any time except to the extent that action has been already been taken in Reliance on it. I further understand that there may be a charge for preparing the information to be released. Applicable charges are in keeping with guidelines issued by the State Board of Medical Examiners.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Name / Signature:

Date:

Witness:

Date:

Your information will be encrypted.