Patient Authorization Disclosure Form

1 HIM Client Services Release of Information T: 713-792-6710 1515 Holcombe Blvd Unit 1209 Houston, TX 77030-4004 Attention MD Anderson Patients: Please use one of the methods listed below to obtain a copy of your medical record. records via your MyChart completed Authorization form to completed Authorization form to completed Authorization form to 1200 Pressler St., Unit 1209, Houston, TX for completing attached form: If you are requesting that your records to be sent to a physician's office or hospital forcontinuing care, please complete the Authorization for Disclosure of Health Informationform. Once the completed form is received, a ROI Specialist will fax your records to thephysician's office or hospital within 24 business hours (3 business days). If you are requesting your medical records for personal use and would like for records tobe sent directly to you via US Postal Service, please complete Authorization forDisclosure of Health Information.

2 Once the completed form is received, a ROI Specialistwill complete your request within 7 to 10 business days. The process is the same forsending your records to third party requesters. Please note that we cannot fax yourrecords back to you, they must be mailed per HIPAA Privacy Rule. If you are requesting your medical records for personal use and would like for records tobe electronically delivered to you via email, please complete the Authorization the completed form, is received, an ROI Specialist will complete your requestwithin 7 to 10 business days. Please note that we require a complete address for allrequests regardless of the delivery method. If you would like to get your records in person the Medical Records office is open from8:00 am to 4:30pm, Monday through Friday, excluding observed holidays. You cancomplete Authorization for Disclosure of Health Information and receive your records atone of the following locations:Lowry and Peggy Mays Clinic (ACB) 1220 Holcombe Blvd, Room Houston, Texas 77030 Main Building 1515 Holcombe Blvd, Room Houston, Texas 77030 If you have any questions, please contact the Release of Information Dept.

3 @ 713-792-6710 and a ROI Specialist will be glad to assist you. Patient :MDA MRN:DOB:SEX:FC:LOCATION:PRINT DATE: 3/7/2022; Authorization for the Useand Disclosure of ProtectedHealth Information (ROI)INS999544 (Rev. 2/28/2022) Authorization for the Use and Disclosure of Protected Health Information (ROI)File Under: HIM ROI AuthorizationPage 1 of 1 Patient :MDA MRN:DOB:SEX:FC:LOCATION:PRINT DATE: 9/24/2021;Release of InformationFee ScheduleINS999544FS (Rev. 9/24/2021)Release of Information Fee Schedule - Texas Health and Safety Code (b)Do Not File in Sanned Medical RecordPage 1 of 1