MIME-Version: 1.0 Content-Location: file:///C:/637A9A45/ReleaseofRecordsOUT1.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Lone Star Physicians Group, P

Lone Star Physicians Group, P.A.

 

Authorization to Relea= se Medical Information

I AUTHORIZE:

From:   Iresh Kumar, MD, FAAP

To:

 

(Child’s physician/Clinic)

PO Box 1480

Address:

       &nbs= p;         Frisco, TX 75034<= /st1:PostalCode>       &nbs= p;            &= nbsp;              &nbs= p; 

City:  <= /span>       &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;      State       &nbs= p;  Zip<= /p>

Phone: 214-705-= 9696

Phone:

 =  = Fax: 214-705-9697

Fax:

 

Child’s Name:

Date of Birth:       &nbs= p;     /       &nbs= p;    /  =

INFORMATION TO BE RELEASED: (Check all applicable)

 

¨ Complete Record

¨ All Progress Notes

¨ Laboratory Reports

¨ Radiology Reports

¨ Immunization Record

¨ Allergy Records

  Consultations<= /p>

¨ Other:

=             &nb= sp;            =             &nb= sp;            =             &nb= sp;        

RECORDS FROM THE TIME PERIOD:       &nbs= p;  /        /       &nbs= p;   through         &nbs= p; /        /

PURPOSE OF DISCLOSURE:  (Check applicable purpose)

= ¨ Continued Medical Care

= ¨ Payment of Insurance Claim

= ¨ Legal

= ¨ Personal

= ¨ Workers’ Compensation Claim

= ¨ Other:

♦I unders= tand that this authorization shall be valid for one year from the date below. I understand that I may revoke this consent at any time except to the extent that action has already been taken.

&#= 9830; I understand that a reasonable fee may be cha= rged for duplication of records. An estimate of those charges will be provided upon request prior to duplication.

The requestor may be provided with a copy of = this authorization.

 

 

Parent/Guardian signature

Date

 

 

Name of Parent/Guardian  (Print)

Relationship to patient:

 

□ Parent    □ Guardian    □ Legal custod= ian

 

SPECIAL AUTHORIZATION: Check applicable box(es) and sign immediately below.

By signing below, I am authorizing the office to release any and all informa= tion regarding:

= ¨ Alcohol       &nbs= p;  ¨ Drugs       &nbs= p;  ¨ Mental Health       &nbs= p;  ¨ Sexually Transmitted Diseases       &nbs= p;

= ¨ HIV/AIDS       &nbs= p; 

 

Note: If this release pertains to alcohol, drug, or mental health information, please note that this information has been disclosed to you from records protected by federal confidentiality rules = (42 CFR part 2). The federal rules prohibit you fr= om making any further disclosure of this information unless additional furth= er disclosure is expressly permitted by written consent of the person to who= m it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug ab= use patient.

Parent/Guardian Signature

Date

 

 

For office use only:

________________________________________________________________= __________________________

MR#            =             &nb= sp;            =   Date        = ;            &n= bsp;            = ;      Initials of Staff Member Sending