Medical Records to Personal MD

This form is used to request your outside medical records to be sent to Personal MD

Patient's Name

Patient's Date of Birth

Date

Name of doctor, office, or hospital that has your medical records

Address (if unknown, please provide as much information as possible)

Phone (if known)

Format: (000) 000-0000.

Fax (if known)

What information would like to be sent to Personal MD

Why do you want to move your medical records?

Other

Frequently asked questions:

This form can not be used to request:

How long will this medical release be effective?

This authorization is valid until:
- The death of the individual
- The minority reaching the age of 26
- Written permission is withdrawn

How do I revoke this request?

l understand that I can withdraw my permission by giving written notice stating my intent to revoke this authorization to the person or organization named in the "Release Protected Health Information To" space above.
I understand that any actions taken between the date of this release and the revocation date can not be withdrawn. In other words, we can't unsend records that we have already sent.

Legal reasons to release your medical records.

Under the HIPAA guidelines, there are occasions where your medical records can be released without your permission. Please see our HIPAA policy on our policies page for details.
I understand that refusing to sign this form does not stop the disclosure of health information that is permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code 181.154c and/or 45 c.F.R. 164.502a1

Signature Authorization:

I have read this form and agree to the uses and disclosures of the information as described.

Today's date and time

Signature of Individual or Individuals Legally Authorized Representative

Request For Medical Records