Arthritis and Autoimmune disease Center, PLLC

Arthritis and Autoimmune disease Center, PLLC
Authorization to Request Medical Records
Patient's Name

First NameLast Name
Birth Date

MonthDayYear
Information Requested

Other
Reason for Request
I request that my complete records or specific information as listed above be released to:

Arthritis and Autoimmune Disease Center,PLLC
425 N. Highland Ave, Sherman, TX 75092
Phone # 903-508-4230 - Fax # 903-553-4388 - Email:pk@dallasarthritis.com
Physician or Practice Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
By signing this form, I authorize you to request confidential health information about me or my child. I understand that I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to the facility receiving the revocation.

If the requestor or receiver is not a health care plan or healthcare provider, the released information may no longer be protected by federal privacy regulations or may be re-disclosed.
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