Memorial Hermann Release – Fill Out and Use This PDF

RELEASE TO: Please provide Name/Address of person/organization to which disclosure is to be made

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

Phone # ___________________________________________________ Fax# _______________________________________________________

DATES OF SERVICE to be released: _________________________________________________________________________________________

__________________________________________________________________________________________________________________________

COPY MY MEDICAL RECORDS TO: please check one  PAPER OR  Electronic Disclosure such as CD

Select Portions of Protected Health Information MHHS is authorized to release

This authorization is valid until the 180th day after the date it is signed unless it provides otherwise, not to exceed 24 months, or

unless it is revoked, and covers only treatment(s) for the dates specified above.

I, the undersigned, have read the above and authorize the staff of Memorial Hermann Health System to disclose such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extend that action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my Protected Health In formation.

Fees/charges will comply with all laws and regulations applicable to release of Protected Health Information. Records will be released after full payment has been received.

Release of Protected

Health Information

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