Patient Release of Medical Records

Please correct the errors described below.

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 :

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.

Your information will be encrypted.