Medical Information Release Form (HIPAA Release)


Please correct the errors described below.

I authorize Michael C. Speck, M.D., P.A. to discuss and/or release my protected health information, including labs, test results, diagnosis and treatments discussed to the following persons:

(By providing your email address you are consenting to Gillespie County Urology signing you up for our Patient Portal)

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We will leave appointment reminder messages to your voicemail but will not leave detailed personal information.


Advance Directive:

Pneumococcal and Influenza Vaccine:

I acknowledge that Michael C. Speck, M.D., P.A. has made available to me a copy of the Notice of Privacy Practices (HIPAA). This notice describes how this office may use and disclose my protected health information. I understand that I can obtain a complete copy upon my request. A copy is also available at

This release of information will remain in effect until terminated by the patient in writing.

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

Your information will be encrypted.