Medical Release Form
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1Authorization for Release of
Medical Records
PATIENT INFORMATION (Please print)
Patient Name
Date of Birth
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RELEASE FROM: Name of facility releasing information
I authorize release of my medical records by RediClinic staff from RediClinic, LLC
9 Greenway Plaza, Suite 2950, Houston, TX 77046
RELEASE TO: Name of patient, physician, or facility receiving information
Please provide my medical records:
by mail [ ]
by fax [ ]
Send to:
Phone
Circle one:
patient, parent, guardian, conservator, physician, or patient representative
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RELEASE INFORMATION
[ ] Transfer of care
[ ] At request of Patient
Reason:
[ ] Change of insurance
[ ] Specialist consult
[ ] Legal
[ ] Moving out of area
Please release the following
(check all that apply and provide dates of service):
[ ]
[ ]
Medical Chart
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/
Lab Report
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[ ]
[ ]
Billing Record
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Other (describe)
> Incomplete information will delay processing.
> Use of this information for any other than the stated purpose is prohibited.
> This information is for the use of the designated recipient only.
AUTHORIZATION
I authorize the release of all information indicated and I am aware that the records released may contain information
relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. I understand that
RediClinic may not condition treatment on my completion of this authorization form. I understand that to the extent
any recipient of this information is not a “covered entity” under state of federal law, the information may no longer be
protected once it is disclosed to the recipient and may be subject to re-disclosure by the recipient.
YES
NO
Initials
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Date
Signature
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Circle one:
patient, parent, guardian, conservator, physician, or patient representative
Printed Name
Note: This authorization is valid for 90 days. The signer may revoke it at any time by submitting a written request
to RediClinic Privacy Officer, 9 Greenway Plaza, Suite 2950, Houston, TX 77046. The revocation will be effective
upon receipt except to the extent RediClinic has already relied on the authorization.
1.866.607.7334
Fax: 1.866.279.9592
Authorization for Release of Medical Records BR1540910 CO.HP.9.9.2-A
October 2009
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Parent category: Legal