Release Of Records

Authorization for Release of Medical Information
Patients Name:
Date of Birth:

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Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 digits of SSN:
Release Of Records

Select TO or FROM Frisco OB/GYN below:
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FromToFrisco Obstetrics and Gynecology, 4461 Coit Rd., Ste 205, Frisco TX 75035 Tel: 972-731-9299 Fax 972-731-9909 Email: Frontdesk@friscoobgyn.com
Name of organization sending to/from
Address:
City/State/Zip
Date Requested:

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Date
Date needed:

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Date
Purpose for this request: (Check One)

Transfer of care OUT to another provider/institutionChange of InsSecond OpinionFor PCPRelease to myselfMoving out of the areaTransferring Care TO Frisco OBGYN
Authorization Valid for: (Check One)

This request onlyOne year from this date of authorizationOr until the date I specify below:
Date

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When my information is used or disclosed I understand that:
- My right to healthcare treatment is not conditioned on this authorization.
- I do not have to sign this authorization in order to receive treatment from the physicians at Frisco Obstetrics and Gynecology P.A.
- When my information is used or disclosed pursuant to this authorization, it may be subject to disclosure by the recipient and may no longer be protected by the federal HIPPA privacy rule.
- I may cancel this authorization at any time by submitting a written request to the address provided at the top of this form.
- The Texas State Board of Medical Examiners allows 2 weeks for the processing of my records.
- According to the Texas State Board of Medical Examiners, the allowable fee is $25 for the first 20 pages and 50 cents for each additional page.
Signature of Patient or Representative:

Clear
Date:

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Should be Empty: