Consent to Release of Medical Information

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:

SEND RECORDS TO:

OBTAIN RECORDS FROM

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

• Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
• TMGC, PA will not condition my treatment, payment, enrollment (if applicable) in a health plan or eligibility of benefits on whether I provide authorization for the requested use or disclosure.
• I am entitled to inspect and obtain a copy of my PHI maintained by TMGC, PA.
• I am required to make a written request for access to PHI using this form, which must be completed in order for TMGC, PA to provide the requested information.
• TMGC, PA has the right to charge me for copying and mailing costs.
• Per HIPAA guidelines, I have the right to request TMGC, PA to amend my PHI or record in the designated record set.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.