AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Please correct the errors described below.

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

Phone: (281) 206-0068

Fax: (281) 499-5045

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:

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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.

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.

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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