hereby authorize Children's Medical Clinics of East Texas, (hereafter collectively referred to as the "Practice") to use and disclose:
In accordance with HIPAA Omnibus Rule of 2013 and Texas HB 300 Law, I understand that I need to provide the specifics of this release request:
3.) The Records will be obtained by:
to pick up a copy of my records.
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.
OR
Your information will be encrypted.