AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Lugo Surgical Group • Rafael Lugo, MD 10800 Gosling Road, Unit 131330, Spring, TX 77393 • Phone: (832) 377-5846 • Fax: 1-888-416-9722
By signing below, I authorize Lugo Surgical Group / Rafael Lugo, MD to release and disclose my complete medical record — including but not limited to office and clinic notes, history and physical examinations, consultation reports, operative and procedure reports, pathology reports, laboratory results, imaging and radiology reports, medication lists, and billing records, for all dates of treatment — to the person or entity I have identified on this form, by the delivery method I have selected.
Sensitive information. I understand that this authorization does NOT include mental health records (excluding psychotherapy notes), drug/alcohol or substance use treatment records, HIV/AIDS test results and treatment, or genetic information, unless I have specifically checked the corresponding box on this form.
Expiration. This authorization expires one (1) year from the date signed, unless I have specified an earlier date or event.
My rights. I understand that: (a) I may revoke this authorization at any time by written notice to the practice at the address above, except to the extent action has already been taken in reliance on it; (b) treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization; (c) information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy law; and (d) I am entitled to a copy of this authorization.
A copy, facsimile, or electronic image of this authorization is as valid as the original, and my electronic signature below is as valid as a handwritten signature. If I am signing as the patient's personal representative, I certify that I have legal authority to act on the patient's behalf and have described that authority