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AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

RELEASE OF MEDICAL RECORDS



Date:__________________                                 Urgent



I hereby authorize:

Physician/Facility/Insurance Co:____________________________________________________


Address:________________________________________________________________________


Tel:____________________________________Fax:____________________________________



To release information regarding my medical history, treatments, disability or benefits to:


Gastrointestinal Care Consultants‚Äč, PA

12121 Richmond Avenue, Suite 424

Houston, Texas 77082

Tel: 832-379-8603 Fax: 832-379-1928



PATIENT'S NAME:_______________________________________________________________


PATIENT'S DOB:_____________________PATIENT'S SSN:_____________________________


SIGNATURE:____________________________________________________________________


WITNESS:______________________________________________________________________




MEDICAL RECORD RELEASE FORM (TO DOWNLOAD)


Please click on the link above to download and print the form.