MEDICAL RECORD RELEASE FORM

Patient Name:

DOB:

SSN:

This request expires on

If left blank, expires 1 year from signing or until revoked in writing.

I authorized you (TRAAC) to request confidential health information about me from the person(s) or entity listed below:

Name:

City:

State:

Phone:

Fax:

The reason/purpose for this request of information is as follows:

Transfer of another provider Personal File Payment of Bill Insurance/Work/Second opinion Attorney Other

If other, Please specify:

Please forward the requested information to:

Texas Regional Asthma & Allergy Center

900 E. Southlake Blvd. Suite 300

Southlake, TX 76092

817-421-0770 (Phone) 817-421-4759 (Fax)

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Guardian Printed Name

Patient/Guardian Signature

Date

Your information will be encrypted.