Medical Records Release

Release Information

Houston Physicians' Hospital to Release Records to Whoever Designated on Form.
    • PHONE # (provide direct # where you can be reached regarding this form or where a voicemail message may be left for you)
    • *“All records” means all protected health information in a designated record set, which includes but is not limited to patient family histories, genetic information, inpatient/outpatient records, medical, dental, psychiatric, alcohol/chemical/substance abuse, HIV/AIDS, pharmaceutical, hospital or physician records, office notes, narrative summaries, correspondence to/from/about me, diagnostic testing results, bills, statements & invoices and information from all other health care providers used for our care and treatment in the hospital/facility). Some records have federal privacy protections. This does not include psychotherapy notes, which require separate “authorization to disclose”.
    • The Facility or Hospital named above is authorized to disclose (provide) the records/information. Persons, facilities, providers or others who are authorized to receive the records/information:
    • Please complete more than one form if multiple disclosures to multiple providers is requested.
  • I authorize the disclosure of the information described. I understand that if the person or entity that receives the described records/information is not a health care provider or health plan covered by federal privacy regulations, the records/information may be redisclosed and no longer protected by those regulations. I also understand that certain records may be protected by federal or state law, and I am requesting that any and all such protected records be released under this authorization. If I revoke this authorization, it will have no effect on actions taken or information already sent as authorized by his form. I understand that the hospital/facility will not condition treatment, payment, enrollment or eligibility on whether I sign the authorization. I also understand that I may have a copy of this form after I sign it. I permit disclosure of information upon presentation of a photocopy of this authorization. I understand that I have the right to revoke this authorization. I may do so by delivering or mailing a written revocation (which is a request withdrawing or cancelling this authorization) to this facility/hospital, any other healthcare provider or attorney or law firm if named above. Unless otherwise revoked, the authorization will expire on the following date, event or condition:
  • If I fail to specify an expiration date, event or condition, this authorization will expire 1 (one) year from date signed. Finally, I understand that there may nominal charges for these records, and that will be discussed with me at the time this “Authorization” is presented or received.
  • I have read and understand this form. I am the patient listed or am authorized to act on behalf of the patient as the patient’s personal representative.
  • (or Patient’s Personal Representative, if applicable)
  • Date of Signature
  • Personal Representative’s relationship or legal ability to represent the patient
  • Printed Name of Patient or Personal Representative:
  • Printed address & telephone number of Personal Representative: