Phone: (682) 558-0342
I authorize Denton Family Clinic to obtain or disclose my health information as described below.
Please release my recordsPlease request my records
Problem listMedication listList of allergiesImmunization recordsMost recent historyMost recent discharge summaryLab resultsImaging reportsConsultation reportsAll
For information request only: The identified information will be used for the following purpose
My personal recordsSharing with other health care providers as needed
Delivery method
Pick up in the officeMail to the address on file *fee will be charged*Email to the address on file
Please select each item below to indicate your understanding
I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.I understand once the information below is released, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.I understand I have a right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the practice. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.I understand authorizing the use or release of this information is voluntary. I need not sign this form to ensure health care treatment.
The identified information may be obtained from the following doctor/hospital/clinic
If I fail to specify an expiration date or event, this authorization will expire twelve (12) months from the date on which it was signed.
Relationship to patient: SelfParentLegal GaurdianOther
[Distribution of copies: original to practice, copy to patient, copy to accompany information released.]
