Release of Records from Previous Physician
Patient Authorization Form / Release of Records
To (previous physician): ____________________________________
I hereby authorize the person(s) listed above to use or disclose the specific information described below, only for the purposes and parties also described below. I understand that the information to be released may include information regarding the following condition(s): drug abuse, alcohol abuse, testing for or infection with human immunodeficiency virus (HIV), psychological counseling, other private information.
Description of the specific information to be used or disclosed:
( ) Complete Medical Record
( ) Medical Records from ________________ to _________________date
( ) Labs
( ) Pap Smear
( ) Mammogram Report
( ) Other ________________________________________________________________
Please send the above information to:
Damian Garcia, M.D.
3450 W. Wheatland Rd. POB II, Ste. 235
Dallas, TX 75237
Phone: (972) 224-1122 Fax: (972) 224-8084
This Authorization shall remain in effect from the date signed below, until: ______________________
(expiration date or event)
I understand that:
• I may inspect or copy the protected health information to be used or disclosed.
• I may revoke this authorization in writing by contacting the office at the address listed above.
• Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer be protected by HIPPA.
( ) if this is checked, I understand that you will receive compensation from a third party for the use or disclosure of my information.