AUTHORIZATION TO RELEASE MEDICAL …

AUTHORIZATION TO RELEASE MEDICAL INFORMATIONTO USMD PHYSICIAN SERVICESI, _____, hereby authorize(Name of patient or legal representative)to RELEASE the following information by mail, fax, electronically or orally to USMD Physician Services: information is for:_____(Name of person/entity who should RELEASE records)For the purpose of: _____(Address of person/entity who should RELEASE records)_____ Date_____ Expiration Date of Authorizationunless otherwise noted, AUTHORIZATION expires 1 year from date of signature aboveName of Patient: _____ Age:_____ Patient/Legal Representative Signature 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.)

authorization to release medical information to usmd physician services i, _____, hereby authorize

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