Release of Records from Previous Physician TO Dr. Garcia

Printable PDF click here Release of Records TO Dr. Garcia

Release of Records from Previous Physician to Dr. Garcia

Patient Authorization Form / Release of Records

From (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 and DATE of Birth

_______________________
Signature

_______________________
Date