Memorial Hermann Information Release
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1One mailing address for all facilities (not a physical address):
Memorial Hermann Release of Information
7737 SWF C94 Houston, TX 77074
Authorization for:
r
Disclosure
r
Inspection
r
Amendment
Of Protected Health Information
Patient Name
Date of Birth
Medical Records#
Address
Telephone #
(
)
I hereby authorize Memorial Hermann Health System to release my records from the following facilities
(please check ONLY facilities that apply):
HOSPITALS
o Memorial City
o NW/Greater Heights
o Southwest
o Northeast
o Sugar Land
921 Gessner Rd
1635 N. Loop West
7600 Beechnut
18951 Memorial N.
17500 W. Grand Parkway South
o Hermann-TMC
o Katy
o Woodlands
o Southeast
o TIRR
6411 Fannin
23900 Katy Fwy
9250 Pinecroft
11800 Astoria Blvd
1333 Moursund
o OSH
o Home Health
5410 West Loop South
o River Oaks
o Outpatient Imaging Centers
o Sports Medicine/Physical Therapy
OUTPATIENT CENTERS:
RELEASE TO: Please provide Name/Address of person/organization to which disclosure is to be made
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Phone # ____________________________________________ Fax # ______________________________________________
DATES OF SERVICE to be released: ___________________________________________________________________________________
Specify dates - this line MUST BE completed
For the following purpose:
o Medical Care
o Legal
o Insurance
o Other (detail below)
_________________________________________________________________________________________________________
COPY MY MEDICAL RECORDS TO: please check one o PAPER
OR o Electronic Disclosure such as CD
Select Portions of Protected Health Information MHHS is authorized to release
o Abstract/Pertinent Information
ENTIRE RECORD INCLUDING - HIV TESTING ONLY
o
o Lab
o Emergency Room
EXCLUSIONS
o
o Radiology Reports
o Admit/Discharge Summary
o MD Progress Notes
o H & P
o Cardiac Studies
o Radiology Digital Images
o Consultation Report
o Itemized Bill
o Face Sheet
o CPT Codes
o Operative/Procedure Report
o Other ________________________________________________________
This authorization is valid until the 180th day after the date it is signed unless it provides otherwise, not to
exceed 24 months, or unless it is revoked, and covers only treatment(s) for the dates specified above.
I, the undersigned, have read the above and authorize the staff of Memorial Hermann Health System to disclose such
information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that
action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this
authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold
harmless the above named facility and its parent company from all liability and damages resulting from the lawful release
of my Protected Health Information.
Date
Signature of Patient/Parent/Conservator/Guardian
Authority/Relationship to Patient
Fees/charges will comply with all laws and regulations applicable to release of Protected Health Information. Records will be released after
full payment has been received.
Release of Protected
Health Information
*73115*
73115
(8/15)
ORIGINAL
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