Texas Medical Records Release Form 3
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Medical Records Release Form
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 physician/person/facility/entity listed below.
Patient Name: __________________________________Date of Birth: ___________________
HIV/AIDS: I consent to the release of any positive or negative test result for AIDS or HIV
infection, antibodies to AIDS, or infection with any other causative agent of AIDS with the rest of
Date:
my medical records. Initial:

The information you may release subject to this signed release form is as follows:
!Complete Records !History & Physical !Progress Notes
!Care Plan
!Radiology Reports !Pathology Reports !Treatment Record
!Lab Reports
!Operative Reports !Hospital Reports !Medication Record !Other (please specify below)

Release my protected health information to the following physician/person/facility/entity:
Name:
Address:
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