Medical Release of Information Form

To release the medical record of the above named patient to (the place you want your medical records to be sent):

Name of recipient: Noushin Firouzbakht, MD

Address: 1325 Pennsylvania Ave, Ste 350

City & State: Fort Worth, Texas 76104

Fax: 817-810-9541

This request and authorization applies to: (initial appropriate line)

All Health Care Information including information relating to HIV/AIDS testing, sexually transmitted diseases, psychiatric disorders / mental health or drug and/or alcohol use. (Please circle all that apply)

All Health Care Information excluding information relating to HIV/AIDS testing, sexually transmitted diseases, psychiatric disorders / mental health or drug and or alcohol use. (Please circle all that apply)

Information used or disclosed pursuant to this authorization may be subject re-disclosure by the recipient and no longer protected.

Treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for participation in research programs, or authorization of the release of testing results for pre-employment purposes. I understand I have the right to revoke this authorization by proving a written request to the above name physician or organization. I understand that the revocation will not apply to information that has already been released in good faith. I understand that the condition for release is not based on payment for treatment and care, enrollment or eligibility on whether I sign the authorization.

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.