Authorization to Release Medical Records
Name of Patient _______________________________________ Date of Birth _________________________
I, the undersigned, authorize the release of, or request access to the information specified below from the
medical record(s) of the above name patient.
PATIENT INFORMATION IS NEEDED FOR:
Continuing Medical Care
INFORMATION TO BE RELEASED OR ACCESSED:
History & Physical Consultation Report Emergency Room Record
Operative Reports
Discharge/Death
Summary Face Sheet
Lab/Path Reports X-Ray Reports/Images Other: ________________
The above information may be released (specify name or title of the individual or the name of the organization to which
records are to be released and the appropriate address):
TO:
Academic Medical Associates Phone 972-445-9515 / Fax 972-445-9414
_________________________________________________________________________________________________________________
(Doctor, Hospital, Attorney, Insurance Company, Self, etc.) Phone Number
2021 N MacArthur Blvd, Suite 435, Irving TX 75061
__________________________________________________________________________________________________________________
Address (Street, City, State and ZIP)
FROM:
__________________________________________________________________________________________________________________
(Doctor, Hospital, Attorney, Insurance Company, Self, etc.) Phone Number
__________________________________________________________________________________________________________________
Address (Street, City, State and ZIP)
I understand that my records are confidential and cannot be disclosed without my written authorization, except when
otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-disclosure
by the recipient and no longer protected. I understand that the specified information to be released may include but
is not limited to history, diagnoses, and/or treatment of drug or alcohol abuse, mental illness, or communicable
disease, including HIV and AIDS.
I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in
reliance upon the authorization.
The authorization will expire six (6) months from the date of my signature, unless I revoke the authorization prior to that
time.
Date: __________________ Signature: __________________________________________________________
Patient or Legally Authorized Representative
_________________________________________________________
Printed Name of Patient or Legally Authorized Representative
________________________________________________________________
Relationship to Patient
