Release Of Records

Authorization for Release of Medical Information

Patients Name:

Date of Birth:

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Last 4 digits of SSN:

Name of organization sending to/from

Address:

City/State/Zip

Date Requested:

Date

Date needed:

Date

Purpose for this request: (Check One)

Authorization Valid for: (Check One)

Date

When my information is used or disclosed I understand that:

My right to healthcare treatment is not conditioned on this authorization.
I do not have to sign this authorization in order to receive treatment from the physicians at Frisco Obstetrics and Gynecology P.A.
When my information is used or disclosed pursuant to this authorization, it may be subject to disclosure by the recipient and may no longer be protected by the federal HIPPA privacy rule.
I may cancel this authorization at any time by submitting a written request to the address provided at the top of this form.
The Texas State Board of Medical Examiners allows 2 weeks for the processing of my records.
According to the Texas State Board of Medical Examiners, the allowable fee is $25 for the first 20 pages and 50 cents for each additional page.

Signature of Patient or Representative:

Date: