• 16651 Southwest Fwy #180

    Phone: (281) 265-8800 Fax: (281) 265-1770
  • AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

  • Please allow up to 7 days for processing. There is a transfer of records fee of $25 for records picked up in our office and $30 to mail, there is no fee if records are send to another doctor directly. The medical records cannot be released until this form is completed and signed by the patient (if at least 18 years old) or parent or legal guardian (if under 18 years old) You must complete this form thoroughly.

  • CONDITIONS OF AUTHORIZATION

  • I have the right to revoke this authorization at any time by writing to the health care provider listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. I understand that signing this form is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal or State privacy regulations.

    A copy of this authorization has been provided. This authorization is valid for 90 days for the release of information as indicated by date of signature below.

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