Medical Record Release Form printable pdf download

Patient

Medical Record Release Form

By signing this form, I authorize Martin Garza MD. P.A.

Phone: (____) ______-______

Fax: (____) ______-______

to release confidential health information on:

Name ____________________________________________ DOB ____/____/_____

Last

First

Middle

Please release copies of medical records to the person(s) or entity below:

Name: _____________________________________

Address: ____________________________________

____________________________________

Phone:

____________________________________

Please release or request the following information:

Immunization Records

Lab or X-ray reports

Sick Visits or Well Exams

Hospital Records

Complete Medical Chart

Reason for Request:

HIV/AIDS: I consent to the release or request of any positive or negative test for AIDS or

HIV infection, antibodies to AIDS or infection with any other causative agent of AIDS with

the rest of my medical records. It may also include information about behavioral or mental

health services, and treatment for alcohol and drug abuse.

Signature of parent/guardian

Date

Witness

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 charges according to rulings set forth by the

Texas Board of Medical Examiners.

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke

this authorization I must do so in writing and present my written revocation to the Office manager. I

understand that this request may be withdrawn in writing at any time except to the extent that action

has already been taken. I understand that the revocation will not apply to my insurance company when

the law provides my insurer with the right to contest a claim under my policy. Unless otherwise

revoked, this authorization will expire on the following date, event, or: _______________ condition.

This authorization expires 90 days from the date signed and covers only treatment for the dates or

diagnosis specified above.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign

this authorization. I need not sign this form on order to ensure treatment. I understand that I may

inspect or request a copy of the information to be used or disclosed as provided in CFR 164.524. I

understand that any disclosure of information carries with it the potential for an unauthorized re-

disclosure and the information may not be protected by federal confidentiality rules.

Medical Record Release Form

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