Authorization Form for Release of Protected Health Information

Please correct the errors described below.

By signing this form, I authorize you to disclose protected health information described below by telephone, fax or mail

Release my protected health information to the following person(s) / entity:

I understand that I have the right to revoke this authorizatiot1; in writing, at any time by sending a written notification
to the following person at the practice:

Fort Worth Perinatal Associates, Office Manager
1250 8th Avenue, Suite 570
Fort Worth, Texas 76104
Ph. 817-332-6667, Fax 817-546-0946

I understand that a revocation is not effective to the extent that the practice has relied on this authorization in its
actions. Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance
coverage, as other law provides the insurer with the right to contest a claim under the policy or the policy itself

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the
recipient and may no longer be protected by federal HIPPA privacy regulations.

The practice will not condition my treatment, payment, and enrolment in a health plan or eligibility for benefits on
whether I provide authorization for the requested use or disclosure.

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.

Your information will be encrypted.