Release or Obtain Medical Records

Authorization to Release or Obtain Medical Records

Full Name *

Email Address *

Phone *

Date of Request *

Address *

City *

State *

Zip*

I authorize my provider at Spine & Sports Therapy to:

Type of health information to be released or obtained:

I understand with the following statement:

My right to healthcare treatment in not conditioned on this authorization. My medical records may be transmitted electronically via fax or email. I may cancel this authorization at any time by submitting a written request to the office at 3100 Timmons Ln, ste 450 Houston, TX 77027, except where a disclosure has already been made in reliance on my prior authorization. If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be re-disclosed. Release of HIV-related information, mental health related are, or substance abuse diagnosis and treatment information requires additional authorization. There may be a change for the requested records.

I understand

Patient / Representative Signature *

Relationship to Patient *

Date of Authorization *

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RelEase or Obtain Medical Records

Authorization to Release or Obtain Medical Records

Houston

Kingwood

The Woodlands

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