Release of Medical Records Release of Medical Records Authorization for Disclosure of Confidential Information pagename Patient Name * Date of Birth Address Authorizes: Name of Person/Facility: Address or Fax Number To release the following medical information to ARH.Check All That May Be Released: History Physical EKG Report Lab Reports X-ray Therapy Reports Operative Report Psychological Reports Care Plan Progress Notes OtherOther Note: Memorial Hermann patients must initial the following statement: “I acknowledge and at this moment consent to such that the released information may contain alcohol, drug abuse, psychiatric, HIV Testing, HIV results, or AIDS information”INITIAL HERE: This authorization covers patient care rendered from:Start Date: End Date: Purpose of Disclosure: Medical Care Insurance Attorney OtherOther The patient agrees that a photocopy of this authorization may be considered valid. Yes No The authorization shall be valid for ninety (90) days from the date of signature below unless revoked in writing by the patient before that expiration. * Clear Date Captcha Submit If you are human, leave this field blank.
