RECEIPT OF RECORDS/ AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Southwest WomanCare OBGYN

7789 Southwest Fwy, Suite 400, Houston, TX 77074 I (832) 649-4273
RECEIPT OF RECORDS/ AUTHORIZATION TO RELEASE MEDICAL INFORMATION
PRINT NAME*
DOB*

MonthDayYear
Date
CURRENT ADDRESS*
HOME PHONE*
WORK PHONE*
I authorize information released from:
Physician Name or Clinic*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Permission to fax:*

YesNo
Fax Number
Please enter a valid phone number.
PUROPOSE OF RELEASE:*

Changing MS/ClinicReferral/ConsultationInsurancePersonal
INFORMATION TO BE RELEASED:*

OB RecordsUltrasound ReportLab ResultsOperative ReportPathology ReportX-Rays, CTs, MRIsOther
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.*

Drug Abuse Diagnosis/TreatmentAlcoholism Diagnosis/TreatmentMental HealthAIDS/HIV test results and related information including high risk behavior documents
Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date
This authorization is valid for six months and may be revoked by the patient (verbally or in writing) at any time 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: