TO BE RELEASED
DATE/ DATES OF SERVICE
REASON FOR RELEASE
p Complete Record
p Progress notes only
p Lab Results only
p Other (specify)
p Continuity of Care
p Coordiation of Care
p Personal
p Other:
a NOTE: If specific dates to be released or a specific provider are not indicated, all records in the category marked will be released.
I understand that this authorization is valid for twelve months unless I notify otherwise. I may revoke this authorization in
writing at any time except to the extent that my record has already relied on this authorization. I may revoke it by mailing
or faxing a written notice to the office at the address/fax number above stating my intent to revoke this authorization. I
understand that the records released may include information relating to Human Immunodeficiency Virus (“HIV”) infection
or Acquired Immunodeficiency Syndrome (“AIDS”); treatment for or history of drug or alcohol abuse; or mental or
behavioral health or psychiatric care. I understand my treatment will not be conditioned by my completion of this form.
The information will be provided to me within 10 business days of my request.
a NOTE: If mailing or faxing this form, please include a copy of your photo ID.
date
signature of patient (or if legal representative-state authority to act)
staff signature / department
date
STAFF
ONLY
Date Released: Released by:
Notes:
last name (please print) first name (please print) date of birth
address
EMAIL
today’s date
Krishna Sunkureddi, MD
Krishna Sunkureddi, MD
Authorization for Release
of Medical Records
I authorize the following protected health information to be released from the medical record of:
p Please call when my records are ready for pick-up p
Ple
ase fax my records p Please mail my records
I understand that to the extent that any recipient of this information, as identified above, is not a “covered entity” under Federal or Texas
privacy law, the information may no longer be protected by Federal and Texas privacy law once it is disclosed to the recipient and, therefore,
may be subject to re-disclosure by the recipient.
Krishna Sunkureddi, MD
1406 Stonehollow Dr. Ste. 600
Kingwood, Texas 77339
Phone: 281-358-0502
Fax: 281-358-0085
phone number
Release Records
p
p
From
To
Release Records
p
p
To
From
name/organization
address
city state zip code
phone fax
I understand that if my record is over 25 pages it may be mailed instead of faxed.
There is a fee of $25 for the first 25 pages and $0.50 for each page after that.
click to sign
signature
click to edit
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click to sign
signature
click to edit
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