An authorization form is required when you are requesting copies of medical records or asking that we disclose your health information to 3rd parties. If you need your record copies to be sent to another health care provider for treatment purposes, you may either submit this form or merely contact the appropriate facility’s medical record department.
By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the person(s) or entity listed below.
I understand that you will provide this information within 15 days from receipt of request and that a fee for preparing and furnishing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners.
