Medical Records Consent

Medical Records Consent

Authorization for Use and Disclosure of Protected Health Information
If you are transferring to us as your primary care provider, we will need records from your previous primary care physician.

If you are coming to us for a specific treatment, but are NOT transferring to us as your PCP, please only request the records relevant to the reason you are coming to see us.
IF YOU HAVE PROBLEMS filling out this online form, please use the printable form on our website! You can find it by clicking here.
Name*

First NameMiddle NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
Date*

MonthDayYear
Date
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState

Zip
Phone*
Health care period of information to be released

ALL DatesPeriod of time
From: (date)*

MonthDayYear
Date
To: (date)*

MonthDayYear
Date
Information to be released

Complete Health RecordDischarge Summary and InstructionsRadiology reportsLaboratory test resultsOffice notes, medication history and correspondenceOther (specify)
You can just Initial the below special requests:
Include Drug, Alcohol or Substance Abuse Records

Clear
Include Mental Health Records

Clear
Include HIV/AIDS Related Information (Including HIV/AIDS Test Results)

Clear
Include Genetic Information (including Genetic Test Results)

Clear
Purpose of request

At the request of the patientTreatment/Continuing Medical CareOther (specify)
Method of sending / Release information:

FaxPaperCDSecure Direct eMessagingAny of Above
I hereby request release of my medical records from the below provider, to K. Paul Gerstenberg, D.O., P.A. (gerstenberg.clinic)

2645 Nall Street | Port Neches, Texas 77651 | Fax: 409.527.3969 | Ph: 409.210.3336
Provider Name
Provider Phone #
Provider Address
Provider Fax #
The individual signing this form agrees and acknowledges the following:

Voluntary Authorization: This authorization is voluntary. Treatment or payment for services will not be conditioned upon my signing of this authorization form.

Right to Revoke and Time Limit: I understand that I have the right to revoke this authorization at any time by submitting a notice in writing to the facility. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. Unless revoked, this authorization will expire 180 days from the date of signature.

Special Information: This authorization may include disclosure of information relating to DRUG, ALCOHOL and SUBSTANCE ABUSE, MENTAL HEALTH INFORMATION, CONFIDENTIAL HIV/AIDS RELATED INFORMATION, and GENETIC INFORMATION only if I place my initials on the appropriate lines above. In the event the health information described above includes any of the types of information, and I initial the corresponding lines in the box above, I specifically authorize release of such information to the person or entity indicated.

Signature Authorization: I have read this form and agree to the uses and disclosures of the information as described. I understand that the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer protected by the Health Insurance Portability and Accountability Act of 1996. The facility, its employees, and physicians are hereby released from any legal responsibility for disclosure of the above information to the extent indicated and authorized herein.
The individual signing this form agrees and acknowledges the above.*

Clear
Should be Empty:

Medical Records Consent

I hereby request release of my medical records from the below provider, to K. Paul Gerstenberg, D.O., P.A. (gerstenberg.clinic)