Release of Medical Records

RELEASE OF INFORMATION

Name of Patient

Date of Birth

Address

Phone

I hereby authorize physicians and representatives of Tomball Healthcare for Pediatrics to obtain confidential information from:

Name

Addres

Phone

Fax

Purpose

Continuation of care legal Attorney Commercial Insurance Personal Use Other

Describe 'Other'

The following information will be released / Obtained (Check beside requested record(s))

Entire Records

Immunization Record

Diagnostic Test Results

Hospital Records

Other

Please Specify 'Other'

I understand that I may revoke this authorization in writing at any time prior to the release of the information specified above. I understand that if the recipient authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal and state privacy regulations. I hold harmless Tomball Healthcare for Pediatrics and / or their representative from liability resulting in the released/obtaining of the above information. This authorization expired 90 days from the date signed.

Pursuant to State and Federal law you are hereby advised that the information that you authorized for release may include: Any/all test results, diagnosis and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol abuse..

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

Relationship to the Patient

Date

NOTICE TO RECIPIENTS OF INFORMATION: This information has be disclosed to you from records whose confidentiality has been protected by Federal Law, Federal Regulation (42, CPR Part 2) prohibit you from making any further disclosure of it without specific written consent of the person to whom it pertains, or as otherwise permitted by such regulation

Your information will be encrypted.