Medical Records Release Form printable pdf download

MEDICAL RECORDS RELEASE FORM

Houston Female Urology][

□ TO □ FROM

Physician _______________________________________

Dr. Christina Pramudji

Facility

_______________________________________

Houston Female Urology, PA

18400 Katy Freeway, Suite 530

Address

_______________________________________

Houston, Texas 77094

(281) 717-4003

City, State Zip ____________________________________

fax (281) 206-7597

Fax Number _____________________________________

Phone Number ___________________________________

Patient Name: ___________________________________________

Date of Birth:________________

Home Address:__________________________________________________________________________

Phone Number:_____________________________________

Information requested: □ All Medical Records □ Laboratory Reports □ Radiology

Other: ____________________________________________

Purpose of Disclosure: (Please select only one box)

Treatment/Continuing Medical Care

Billing or Claims

Insurance

Legal Purposes

Disability Determination

School

Employment

Other ________________________

To be completed only for third-party disclosures. (If the disclosure is for personal use, skip this section.)

I want the requested medical records to be sent to the third-party (for example, an employer or a school) I have indicated

below. My completion of this form serves as authorization for Houston Female Urology to disclose these records to this

person or group. I understand that once my information leaves Houston Female Urology, Houston Female Urology is no

longer able to protect the information, and the recipients of my information may not be legally required to protect my

information.

Name:______________________________________________Phone_______________________________

Mailing

Address:__________________________________________________________________________________________



Terms of Authorization: I understand that fees may apply. I also understand this authorization may be revoked in writing

at any time, according to the instructions in Houston Female Urology Notice of Privacy Practices, except to the extent that

action had been taken in reliance on this authorization. If the person or entity that receives the information is not a

healthcare provider or health plan covered by federal privacy regulations, the information described above may be re-

disclosed and no longer protected by those regulations. The information released may contain information related to AIDS

or HIV infection; drug or alcohol abuse; mental or behavioral health or psychiatric care, except for psychotherapy notes.

Houston Female Urology will not condition treatment or payment on my completion of this form.

Signature:________________________________________________________Date: __________________________

Printed name:_______________________________________Relationship to patient: ____________________________

Medical Records Release Form

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