Record Release Form

I understand that this authorization will be valid for one (1) year unless otherwise stated or revoked written notice is given.

By signing this form, I authorize these providers to release or receive confidential health information about me, by releasing either a full copy or a summary of my medical records/protected health information. I understand that this information will be provided within 15 days from receipt of request and that a fee for preparing and furnishing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners.