Release of Medical Information

To release the following information from the health records of:
Patient Name:   Full Name   DOB:   Date   

I hereby authorize :
Physician:   Physician Name   
Address:   Street Address      City   State   Zip   
Phone:      Phone Number   Fax:      Phone Number   

Information is to be released to :
Physician/Clinic/Person:   Physician/Clinic/Person Name   
Address:   Street Address      City   State   Zip   
Phone:      Phone Number   Fax:      Phone Number   

Expiration date of authorization

This authorization is effective through   Date   unless revoked or terminated by the patient's personal representative.

Note: Please select an expiration date of your choice. As long as a current release is on file in the patient chart you do not need to fill out this form again until it expires. 

Right to terminate or revoke authorization
 You may revoke or terminate this authorization by submitting a written revocation to: 

Clinical Pediatric Associates of Irving & Las Colinas, PA dba Clinical Pediatric Associates of North Texas
Attn: Administrator 
2020 W. State Hwy. 114, Suite 300 Grapevine, TX 76051

Right of the individual
You may inspect or copy information used or disclosed under this authorization.
You may refuse to sign this authorization.

Signature of Patient Rep:  Signature   Date:   Date   
Patient Rep Name:   Full Name Relationship to Patient:   Relationship     Phone Number:      Phone Number   
Address:   Street Address      City   State   Zip