RELEASE IN MEDICAL RECORDS

Patient Name *
Account Number *
Social Security Number: *
Date of Birth *
To Doctor: *
I, the undersigned, authorize you to furnish a copy of the following medical records:
Covering Period From: *
to *
*
My DiagnosisHospital Admission SummaryOperative report’ s, findings & complicationsER TreatmentHospital NotesDr.’s NotesMy PrognosisHospital Discharge Summary
Other
I authorize the release to
Name *
Phone # *
Address *
502 S. Closner Blvd.Edinburg, Texas 78539Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Fax #:
For the following purpose and that purpose only, any other use is forbidden: *
This authorization specifically authorizes Dr. *
to disclose records of alcohol and substance abuse.
This authorization specifically authorizes Dr. *
to disclose HIV test results or diagnosis of AIDS and AIDS related conditions.
I also understand that I may revoke this authorization at any me, except to the extent that Dr. Has already taken action in reliance on it(e.g. probation, parole, etc.), and that in any event this authorization expires automatically as described below.If *
Signature of Patient or Authorize *
Relationship to Patient *
Legal Representative *
Date *
Witness Signature *
Date *

Patient Name: *

Date of Birth: *

CODE	DESCRIPTION	TOT AL CHARGE
4764	AFFIDAVIT	$15.00
314	DISABILITY STATEMENT	$10.00
316	ITEMIZED STATEMENT	$5.00
311	MEDICAL RECORDS/20 PGS	$25.00
4082	MEDICAL RECORDS/ADDT’L	$ 0.50 Per Page
319	NARRATIVE REPORT	$350.00
315	SHORT LETTERS	$15.00
5047	DEPOSITION BY WRITTEN QUESTION	$50.00
311	TEXAS REHAB/RECORDS	$18.00
332	FILMS PER SHEET	$ 8.00
	CD	$ 10.00
	NOTARY	$ 6.00