Rocky Creek Family Medicine (RCFM) 3281 Rocky Creek Drive, Ste 500 Missouri City, TX 77459 Ph: 281-206-0068 Fax: 281-499-5045
To Release Information to
Purpose of Release
Information to be released
Sensitive information to be released
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereum, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
This authorization may be revoked at any time except to the extent any person has taken action in reliance upon this authorization. Further details on the revocation of this authorization are included in the facility’s notice of privacy practices. The revocation must be made in writing to the facility releasing the information. The revocation may be the basis for denial of health benefits or other insurance coverage or benefit. Information released pursuant to this authorization may be subject to re-release by the recipient and may no longer be protected by federal or state law. A copy of this authorization is available upon request.
RCFM will not condition treatment on the signing of this authorization. I may refuse to sign. If I refuse to sign, it may result in an improper diagnosis, treatment, denial of coverage, denial of claim benefits, denial of other insurance, or other adverse consequences.
This authorization expires 12 months from the date of my signature below.During the 12-month period, RCFM may make subsequent disclosures to the recipient named above.
I, the undersigned, hereby authorize the release of the protected health information described above subject to the restrictions described above:
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.
DEADLINE FOR RELEASE OF RECORDS: THE REQUESTED COPIES OF MEDICAL AND/OR BILLING RECORDS OR A SUMMARY OR NARRATIVE OF THE RECORDS SHALL BE FURNISHED BY THE PHYSICIAN WITHIN 15 BUSINESS DAYS AFTER THE DATE OF RECEIPT OF THE REQUEST AND REASONABLE FEES FOR FURNISHING THE INFORMATION.