Fillable Medical Records Release - Neurotexas printable pdf download

Fax: 512-474-1118

Email: jbravo@neurotexas.net

Authorization Form for the Release and Disclosure of Protected Health Information

Patient Name: ___________________________________________________________

Date of Birth: ________________

Address: _________________________________________________ City: ______________________________ State : _______________

Zip Code: ________________

Phone #: ____________________________________

Fax #: ___________________________________

I hereby authorize the release and disclosure of my protected health information to:

to be mailed

to be picked up at office

to be faxed

(choose one of the following options)

1. Self:

2. Other Physician(s):

Name: ____________________________________________________________ Phone #: _______________________________________

Address: _________________________________________________________

Fax #: ______________________________________

City: _____________________________________

State: __________

Zip Code: ___________________

Please send the following records: (check all that apply)

Office Visit Notes

Radiology Reports

Operative Reports

Other (Specify)

Date(s) of Service: _______________________________________________________

_________________________________________

I understand that the information in my health records may include information relating to communicable disease, Acquired

Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV), genetic testing or screening, behavioral or mental health,

alcohol/drug (substance) abuse or any such related information. This authorization is voluntary and I may refuse to sign this authorization.

I further understand that my health care and the payment of my health care will not be affected if I do not sign this form. The authorization

will expire by law 180 days from the date of this authorization unless I specify otherwise.

I understand that I may inspect or copy the information to be used or disclosed, and that information used or disclosed pursuant to the

authorization may be subject to redisclosure by the recipient, and may no longer be protected by federal and state privacy regulations. I

understand that NeuroTexas, PLLC charges a processing fee for this service. According to the regulations outlined by the Board of Medical

Examiners and in compliance with Texas statute, a fee of $25.00 for the first 20 pages and $0.50 per page thereafter, plus postage will be

charged for record requests.

I further understand that I may revoke this authorization at any time by notifying NeuroTexas, PLLC. If I revoke this authorization, I must

do so in writing and the written revocation must be signed and dated with a date that is later than the date on this authorization. The

revocation will not affect any actions taken before the receipt of the written revocation.

_______________________________________________________________________

__________________________________

Printed Name of Patient or Patient’s Representative

Date

_______________________________________________________________________

__________________________________

Signature of Patient or Patient’s Representative

Relationship to Patient

Medical Records Release - Neurotexas

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