Memorial Hermann Release PDF Details

Memorial Hermann, a top healthcare system in Texas, has released a new form patients must sign before they can be admitted to the hospital. The new form, called the Memorial Hermann Release Form, gives the hospital permission to share the patient's medical information with certain third-party vendors. While some people are concerned about the privacy implications of this new form, Memorial Hermann maintains that it is necessary in order to provide patients with quality care. Patients who do not want their information shared with third-party vendors are free to refuse to sign the form.

Here is the details about the file you were in search of to fill out. It can show you the time you will require to complete memorial hermann release, exactly what parts you will have to fill in, etc.

Form NameMemorial Hermann Release
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesmemorial hermann discharge papers, memorial hermann hospital discharge, memorial hermann release of protected health information, hermann medical release form

Form Preview Example

One mailing address for all facilities (not a physical address):




Memorial Hermann Release of Information




7737 SWF C94 Houston. TX 77074

 Inspection  Amendment Of Protected Health Information

Authorization for:  Disclosure

Patient Name




Date of Birth

Medical Records#














Telephone #









I hereby authorize Memorial Hermann Health System to release my records from the following facilities


(please check ONLY facilities that apply):















 Memorial City

 NW/Greater Heights

 Southwest

 Northeast


 Sugar Land


 Katy


 Woodlands

 Southeast




 Cypress


 Pearland

 Katy Rehab









 River Oaks

 Outpatient Imaging Center

 Sport Medicine/Physical Therapy

 Medical Group


 Katy

 Convenient Care Center


 PhyTex/Mischer Assoc.

 Home Health

 Physicians at Sugar Creek

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



Phone # ___________________________________________________ Fax# _______________________________________________________

DATES OF SERVICE to be released: _________________________________________________________________________________________



Specify dates - this line MUST BE completed

For the following purpose: Medical Care



Other (detail below)


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

Abstract/Pertinent Information




Emergency Room


Radiology Reports


Admit/Discharge Summary


MD Progress Notes



Cardiac Studies

Radiology Digital Images

Consultation Report

Itemized Bill

Face Sheet

CPT Codes

Operative/Procedure Report

Other _______________________________________________________

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.





Signature of Patient/Parent/Conservator/Guardian

Authority/Relationship to Patients

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

73115 (10/17)

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hermann medical release form blanks to consider

The application will require you to fill out the For the following purpose Medical, Select Portions of Protected, AbstractPertinent Information, ENTIRE RECORD INCLUDING HIV, EXCLUSIONS, Radiology Digital Images, This authorization is valid until, Date Signature of, and Feescharges will comply with all field.

Filling in hermann medical release form stage 2

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