• Medical Records Request Form

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  • I, the undersigned, authorize the release of the medical information specified below from the medical records of the above named patient:

  • The above information may be released to:

  • Frisco
    Centennial Medical Pavilion I 4401 Coit Road,
    Suite 411
    Frisco, TX 75035

  • McKinney
    Eldorado Office Park
    6717 West Eldorado Parkway
    Suite 140
    McKinney, TX 75070

  • Plano
    5512 W Plano Pkwy.
    Suite 100
    Plano, TX 75093

  • Prosper
    940 South Legacy
    Suite 30
    Prosper, TX 75078

  • Anna
    2016 W. White St.
    Suite 100
    Anna, TX 75409

  • Right to Inspect or Copy the Health Information to be Disclosed
    You have the right to inspect or copy the health information that is to be used or disclosed. You may obtain access to your health information or obtain copies by contacting the Privacy Officer. We recommend you keep a copy of your
    medical records for your files.

    Right to Refuse to Sign this Authorization
    You have the right to refuse to sign this authorization. ENTTEX will not condition your treatment, payment, and enrollment in a healthplan or eligibility for benefits on whether you provide authorization for the requested use or disclosure.

    Signature
    I have had an opportunity to review and understand the content of this authorization form. By signing this authorization,I am confirming that it accurately reflects my wishes.

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