Medical Records Consent

PLEASE RETURN RECORDS TO FAX 214-618-5506

Authorization to Release Medical Records
Patient Name*
Email Address*
DOB*
MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code
Telephone #*
Authorization of Medical Records to be Disclosed:
To be released from (Facility Name)*
Surgeon’s Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Telephone #
Fax #
I also authorize the release of my medical records from the Hypospadias Specialty Center for medical necessity.
Date(s) of Service:
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Information Being Disclosed*
Printed Name of Patient (18 or older)/Parent/Guardian if Patient is Under 18*
Patient (18 or older)/Parent/Guardian Signature*
Name
This field is for validation purposes and should be left unchanged.