Medical Records Request Form

I hereby authorize the Medical Group / Physician named below to release my medical record/protected health information to Laredo Arthritis & Rheumatology Center. PLLC:
Medical Group(s) / Physician(s):
Patient Name:
Age
DOB
MM slash DD slash YYYY
Social Security
Home Phone
Mobile Phone
Work Phone
Please Release the following:
- Entire Record
- Clinical Notes
- Third Choice
- Labs
- X-Rays
- Diagnostic Tests
- Other: Biopsies, MRl's, EMGs, CT Scans, PFT'S, echocardiogram reports
Signature
I give permission for the release of any information in my records including information relevant to substance abuse, psychiatric/mental health services, and/or HIV information. I grant this authorization for a period of one hundred eighty (180) days. I may revoke this authorization at any time in writing although I cannot undo its prior use.
Date
MM slash DD slash YYYY