Release of Protected Health Information Authorization

Release of Protected Health Information Authorization
Patient Name

First NameLast Name
Patient Contact Number:
Patient Date of Birth:

MonthDayYear
Date
Doctor/Facility Name
Doctor Facility Phone Number

Area CodePhone Number
Doctor/Facility Fax Number
I hereby authorize to release of medical records for the purpose of clinical research preparatory review, safety evaluation, and treatment to DM Clinical Research/Texas Center for Drug Development, Inc.
Please Leave this Section as BLANK -- For Office Use ONLY
Requested By Doctor Name

First NameLast Name
The following record(s) are being requested for time period
Enter Time Period - E.g. 2018 to Present
1.
Visit Notes
2.
Lab Reports
3.
Medications
4.
Any other
I, the undersigned, have read the above and authorize the facility named above to disclose such information as herein contained. I have the right to revoke this authorization in writing at any time, except to the extent that action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above-named facility and its parent company from all the liability and damages resulting from the lawful release of my Protected Health Information (PHI)

Signature of Patient/Parent/Guardian
Please enter your signature
Patient Signature
This Release Of Patient Information will self-expire 1 year from the date of patient signature.
Date

MonthDayYear
Date
Should be Empty: