Medical Records Release Form

Patient Name: ___________________________________ Date Of Birth: ________________

Patient Name: ____________________________________Date Of Birth: ________________

Patient Name: ___________________________________Date Of Birth: ________________

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the person(s) or entity listed below.

Patient Name:

Release my protected health information FROM the following person(s)/entity:

Name: _______________________________________________________________________

Phone: _______________________ Fax: _________________________________________

Limitations on the information you may release subject to this Release Form are as follows:

Release my protected health information TO the following person(s)/entity:

Name: BHARGAV R. TRIVEDI M.D. PHONE 817-293-9008

Street: 11797 SOUTH FREEWAY SUITE 326

City: BURLESON State: TEXAS Zip:76028

The reasons or purposes for this release of information are as follows:

CONTINUING MEDICAL CARE

Patient Signature [or parent, guardian or legal representative]:

________________________________________________________ Date: ______________

I understand that you will provide this information within 15 days from receipt of request and that a fee for preparing and furnishing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners.

Fax Cover Sheet

CAUTION: CONTAINS CONFIDENTIAL HEALTH CARE INFORMATION

To:	From:
Fax:	Phone:
Date:	Fax:
	Pages:
Re:

Comments:

Confidentiality Notice

The document accompanying this facsimile transmission contains confidential information belonging to the sender that is legally privileged, and not intended for public use. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this telecopied information is strictly prohibited. If you have received this document in error, please notify us by telephone immediately.