AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
Patient Name:____________________________________________________________ Phone Number: ___________________________
Other Names Used: _________________________ Date of Birth: _________________Social Security Number: XXX --______ - ________
I, the undersigned, authorize the release of or request access to the information specified below from the medical record (s) of the above-named
patient.
PATIENT INFORMATION IS NEEDED FOR: PLEASE SELECT ONE OPTION
Continuing Medical Care Military Personal Use School Insurance
Legal Purposes Social Security/Disability Other: _________________________________________________
DATE (s) OF TREATMENT: __________________________________________________________________________________________
INFORMATION TO BE RELEASED OR ACCESSED:
Clinic Notes Consultation Report Immunizations All Records
Procedure Notes EKG Reports Medication/Prescription List
Lab/Pathology Reports Radiology Reports Problem List
Behavioral Health Radiology Images Other _________________________________________________
FORMAT REQUESTED FOR INFORMATION TO BE PROVIDED:
Paper Electronic media, as available * Release to MyChart account, as available*
(* only applies to data stored electronically)
METHOD OF DELIVERY:
Pick Up (You will be notified via a telephone call when records are ready for pick up)
Mail to Address listed below
Fax (Provide recipient information below)
________________________________
Phone
______________________________________________________________________________
Physician/Clinic name to release your records
May release the above information to:
I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.
Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected. I understand
that the specified information to be released may include, but is not limited to: history, diagnoses, and/or treatment of drug or alcohol abuse, mental
illness, or communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS).
I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for
participation in research programs, or authorization of the release of testing results for pre-employment purposes. I understand that I may revoke
this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. I understand I may be
charged a retrieval/processing fee and for copies of my medical records according to Texas Hospital Licensing law.
This authorization will expire One Hundred Eighty (180) days from the date of my signature unless I revoke the authorization prior to that time or
unless otherwise specified by date, event, or condition as follows:
_____________________________________________________________.
Date: _____________________ Signature: ________________________________________________________________
Patient or Legally Authorized Representative
________________________________________________________________
Printed Name of Patient or Legally Authorized Representative
__________________________ ________________________________________________________________
For Department Use: MRN/Acct # Relationship to Patient
_________________________________________________________________________________________________________________
AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
(Rev. 08/18) PAGE 1 of 1 PATIENT IDENTIFICATION
Texas Health Physician Group *9810*
Name of Person or Practice
Address (City, State and ZIP Code)
Phone Number
_____________________________________________________________________
_____________________________________________________________________
_____________________________
_____________________________
FAX Number
_____________________________________________________________________
Address (City, State and ZIP Code)
Note: This form must be
completed, printed and a
hard copy brought to your
office appointment.
