Patient Release of Medical Records

Patient's Name

Date of Birth

SS #

I request and authorize

Address/Phone/Fax

To release my medical records to:

Pain Specialty Consultants, P.A.

Prafulla Singh, M.D.

1200 Brooklyn Ave, # 140

San Antonio, TX 78212

Please mail records/ Please fax records

Information to be released :

Copy of complete health records

Other

If other, please specify.

I understand that my express consent is required to release any health care information relating to testing diagnosis, and / or treatment for HIV, sexually transmitted disease, psychiatric disorders/ mental health, or drug and / or alcohol use. You are specifically authorized to release all health care information relating to such diagnosis, testing or treatment.

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.

Signature of Patient/ Authorized Representative

Relationship

Date

Your information will be encrypted.