Medical Records Release

Submitted by admin on Fri, 08/12/2011 - 3:23pm

Submission Date

Month

Day

Year

Submission Time

Patient First Name: *

Please enter your first name here.

Patient Last Name: *

Please enter your last name here.

Date of Birth: *

Month

Day

Year

Social Security #: *

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Telephone Number: * ( ) -

This letter will authorize The ENT Center of New Braunfels to provide a copy, summary, or narrative of my medical records (as indicated by the selection below), or to otherwise release confidential information. At this time I am requesting the following:

This Request is for: *

Complete Chart

Records of Care for Specific Dates of Service (list dates of service below)

Records of care concerning the following condition(s)

From Date:

Month

Day

Year

To Date:

Month

Day

Year

Conditions:

List of condition(s) to be included in the Release of Records.

Reason(s) or Purpose(s) for this release of information: *

The above listed records should be released FROM:

Provider/Person(s)/Entity: *

Street: *

City: *

State: *

Zip: *

Fax Number: * ( )

- -

Telephone Number: * ( )

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The above listed records should be released TO:

Provider/Person(s)/Entity: *

Street: *

City: *

State: *

Zip: *

Fax Number: * ( )

- -

Telephone Number: * ( )

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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.

By placing a check mark in this box, I hereby authorize the release of my medical records as provided above.

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Medical Records Release

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Guadalupe Regional Medical Center

Christus Santa Rosa Outpatient Center

Christus Santa Rosa

Central Texas Medical Center

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