Medical Records Release Form

Please send my records to:

Memorial City Pediatrics

915 Gessner Suite 985
Houston. Texas 77024
Office (713) 461 91 00
Fax (713) 461 01 76

Records to be released from

(This consent and authorization Include, for the period, Indicated, those care and treatment records designated, pertaining to physical illness; emotional/mental illness; AIDS/HIV test results, diagnosis, treatment or related Information (if any); and/or alcohol and drug use.)

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.

• I understand that Memorial City Pediatrics, may not condition my treatment on whether I sign this authorization unless specified above, I can Inspect or copy me protected heath Information to be used or disclosed. I authorize Memorial City Pediatrics to use and disclose the protected health information specified above. ·
• I understand that Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal HIPM privacy regulations,
• I understand that I may revoke this authorization at any time except To the extent that action has been taken In reliance on It, This authorization will expire ninety (90) days from the date of my signature.
  
  

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.