AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORDS

AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORDS

  • Enter the last 4 digits of your social security
  • Please release my medical records from:


    Name of Individual or Organization records being released to:
    J.WILTZ LAW PLLC,
    PO Box 660675 #91832,
    Dallas TX 75266;
    Toll Free: 1.888.874.5879;
    Direct Phone: 1.214.477.3774;
    Fax: 1.888.874.5879

    INFORMATION TO BE RELEASED FOR DATE RANGE
    Abstract Summary (History/Physical, Procedure Reports, Pathology, Consultations, Test Results, Discharge Summary) Progress Notes Consultations Operative Notes Laboratory Test Results Diagnostic Tests Emergency Medication Provider Orders Nurses’ Notes Radiology Reports Discharge Summary Billing Records

    The information will be used or disclosed at the request of the individual. I am the patient or legally authorized representative of the patient (if patient is a minor or unable to sign) and hereby authorize the release and disclosure of my individually identifiable health information as described above. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form. I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider, the released information may no longer be protected by federal and state privacy regulations. I further understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: 2 years from the date the release is signed. If I fail to specify an expiration date, event or condition, this authorization will expire in one year. Information disclosed pursuant to this authorization may be redisclosed by the recipient and no longer protected by the federal privacy regulations. I understand that treatment or payment cannot be conditioned upon signing or refusal to sign this authorization.