Request for Records

AUTHORIZATION FOR REQUEST OF MEDICAL RECORDS
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
Patient Information
Patient First & Last Name*
Date of Birth*

MonthDayYear
Date
Patient Phone #*
Format: (000) 000-0000.
Releasing Physcian/Organization Information
Physcian/Organization Name*
Phone # *
Fax #*
I hereby authorize the release of my medical records to the following:

JENNIFER C BROOKS, M.D., F. A. C. O. G.

Phone: (817) 334-0562 | Fax: (817) 335-4328
Date

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Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR REQUEST OF MEDICAL RECORDS