Medical Records Release Authorization

Medical Records Release Authorization
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous physician or facility*
Physician or facility location (City and State)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician or facility Phone Number*
Physician or facility Fax Number (if known)
I hereby authorize the above physician/facility to release my individually identifiable health information as outlined below to:

TLC Family Health (Flower Mound, TX, Phone: 972-914-9421, Fax: 915-331-9481)

which may include information such as Human Immunodeficiency Virus (HIV) status and Acquired Immune Deficiency Syndrome (AIDS), mental illness (except psychotherapy notes), chemical or alcohol dependency, laboratory and imaging reports, medical history, treatment, and related information. I understand that this authorization is voluntary.
Information to be released:*

Complete records, including lab and imaging reports, vaccinations, and preventive measuresI only need the following records:
Include dates of service: Date* to Date*.
Purpose of releasing records*
Signature*

Clear
Date Signed*

MonthDayYear
Select:*

I am the patientI am the legal guardian for the patient (indicate relationship below)*
*Relationship
Should be Empty: