Medical Release Form

Medical Release Form
To release the following information from the health record (s) of:
Patient's Name Date of Birth:
I hereby authorize:

(who has the medical records)
Physician:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone NumberFAX
Information I need released:
Complete Medical RecordsImmunization RecordLabsOther
Information is to be released to:

(where you want medical records to go)
Physician / Clinic / Person:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone NumberFAX
Expiration date of authorization:
This authorization is effective through: blanks unless revoked or terminated earlier by the patient or 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 & Los 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 representative:

Name
DateRelationship to patient
Printed name of patient representative:

Name
DateRelationship to patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Potential for Re-disclosure

The person or organization to which this information has been disclosed may disclose it again under this authorization. It may not be possible to ensure your right to the protection of the privacy of this information once Clinical Pediatric Associates of Irving & Los Colinas, PA dba Clinical Pediatric Associates of North Texas discloses it to another party. The privacy of this information may not be protected under the federal privacy regulations.
Should be Empty:

Medical Release Form

To release the following information from the health record (s) of:

I hereby authorize:

Information I need released:

Information is to be released to:

Expiration date of authorization:

Right to terminate or revoke authorization:

Right of the individual:

Potential for Re-disclosure