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.
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