Request InformationRecords to be sent to Houston Physicians’ HospitalPatient NameDOB#Patient's AddressCity/State/ZipPHONE # (provide direct # where you can be reached regarding this form or where a voicemail message may be left for you)Home#Cell/Other#Disclosure of protected health information is made at my request for:Change of InsuranceChange of PhysicianReferrelPersonal RecordsLegal or attorny useDESCRIBE WHAT SPECIFIC RECORDS MAY BE DISCLOSED TO HOUSTON PHYSICIANS’ HOSPITAL/CHECK ALL THAT APPLY:All Records of treatment*Billing records, statements for servicesNursing notes, documentationOperative or procedure notesPhysician notes, orders, history & physicalLab/ diagnostic/ test results onlyImaging/ Radiology reportsDischarge Summary*“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 RECEIVE the records/information. Please send the information to: HOUSTON PHYSICIANS’ HOSPITAL 333 N. Texas Avenue, Suite 1000 Webster, TX 77598 Attention: Health Information Management DepartmentI 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.Signature of Patient(or Patient’s Personal Representative, if applicable)Date of SignaturePersonal Representative’s relationship or legal ability to represent the patientPrinted Name of Patient or Personal Representative:Printed address & telephone number of Personal Representative:CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.