Transcription of AUTHORIZATION TO RELEASE MEDICAL …
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AUTHORIZATION TO RELEASE MEDICAL …
, _____, hereby authorize(Name of patient or legal representative)USMD Physician Services to disclose the following information by q mail q fax q orally to:Name: _____(Name of person/entity who should receive records)Address: _____(Address of person/entity who should receive records)City, State, Zip Code: _____Phone Number: _____ Fax Number: _____From the health records of: _____ (Name of person whose record will be disclosed) Name of Patient: _____ Age:_____ For the purpose of:_____ All Health Information Statements of Charges or Payments AIDS or HIV Information Initials _____ History and Physical Examination Copies of Records of Reports Provided to the Above Named ( Hospital, Lab, Clinic, etc.) Mental Health and/or Alcohol & Drug Abuse Treatment Initials _____ Record of visit for a specific date(s).
45.Authorization.Release.FROM.USMD.Rev02116 I, _____, hereby authorize
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