Release of Records from Previous Physician

Printable PDF Release of Records Form

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.

_____________________________________________________________
Patient Name

_______________________
Signature

_______________________
Date