RELEASE | AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Southwest WomanCare OBGYN

7789 Southwest Fwy, Suite 400, Houston, TX 77074 I (832) 649-4273

AUTHORIZATION TO RELEASE MEDICAL INFORMATION
PRINT NAME
DOB

MonthDayYear
Date
CURRENT ADDRESS
HOME PHONE
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
I authorize information released from:

Southwest WomanCare OBGYN

7789 Southwest freeway, suite 400

Houston, Texas 77074

Please send my records to:
Physician Name or Clinic
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Permission to fax:
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
PURPOSE OF RELEASE:
INFORMATION TO BE RELEASED:

Other
DATES OF SERVICE:
From:

MonthDayYear
Date
to:

MonthDayYear
Date
PROTECTED OR SENSITIVE INFORMATION: I understand that certain information cannot be released without specific authorizations required by State/Federal Law.
By signing, I authorize Southwest WomanCare OBGYN to release the following protected or sensitive information.
Printed Name
Signature
Date

MonthDayYear
Date
This authorization is valid for six months and may be revoked by the patient (verbally or in writing) at anytime prior to six months.

**THE STATE BOARD OF MEDICAL EXAMINERS, CHAPTER 165.2(b) Deadline for Release of Records require: "The requested copies of medical and/or billing records or a summary or narrative of the records shall be furnished by the physician within 15 business days after the date of receipt" A fee for preparing and furnishing this information may be charged according to ruling set forth by the Texas State Board of Medical Examiners.
Should be Empty: