Texas Midwest Gastroenterology Center
hereby authorize the designated medical custodians or database custodians of Texas Midwest Gastroenterology Center, PA (TMGC, PA) to release/request my protected health information (PHI) as described below:
Texas Midwest Gastroenterology Center, PA
Yogeshkumar Patel, MD
14 Hospital Drive, Abilene, Tx 79606
Phone: (325) 795-2100
Fax: (325) 795-2113
Description of records to be used/disclosed (i.e. “procedure reports”, “laboratory/pathology reports”, “ENTIRE RECORD”, etc.). Please include date(s) of service or specify “ALL”.
(Note: This Authorization does not extend to HIV test results, outpatient psychotherapy notes, drug or alcohol treatment records, genetic testing or venereal disease, unless specifically requested above.)
This authorization shall be in force and effect for 365 days, at which time this authorization to use or disclose this protected health information expires. I have the right to revoke this authorization in writing, at any time, by sending such written notice to Texas Midwest Gastroenterology Center, Medical Records, 14 Hospital Drive, Abilene, TX 79606. A revocation is not effective to the extent that have relied on the use or disclosure of the PHI.
I understand and agree that
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