AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

3281 Rocky Creek Drive, Ste 500 Missouri City, TX 77459

Phone: (281) 206-0068

Fax: (281) 499-5045

Patient's Name:

Date of Birth:

Previous Name:

Social Security #:

I request and authorize (provider or facility/hospital of whom we are requesting records):

Phone Number:

Fax Number:

To release healthcare information of the patient to:

Deirdre McMullen M.D., Tiyashi Choudhury M.D., and/or Hillary Spears FNP
3281 Rock Creek Drive, Ste 500
Missouri City, TX 77459
Phone: (281) 206-0068
Fax: (281) 499-5045

This request and authorization applies to:

Healthcare information relating to the following

treatment, condition, or dates:

All healthcare information

Other:

Definitions: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital war, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereum, HIV(Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

Yes No

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Yes No

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.

Patient/Guardian Signature:

Date:

Print Guardian Name, if applicable:

Relationship:

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.

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