Authorization to Disclose Protected Health Information – Greater Houston OB/GYN

Name(Required)

First Last

Today's Date(Required)

Address(Required)

Street Address City State ZIP

Phone(Required)

Email(Required)

I hereby authorize: Greater Houston OB/GYN, L.L.P. 929 Gessner Rd., Suite 21S0 Houston, TX 77024(Required)

Dr. Carol M. Storey

Dr. Camille V. Boon

Dr: Anne v. Gonzalez

Dr. Sharon S. McCloskey

Dr. Ashley E. Hester

To Disclose or Receive From(Required)

To Disclose To

To Receive From

Person/Organization Name(Required)

Phone(Required)

Address(Required)

Street Address City State Zip

Records are requested for the purpose of:(Required)

Continuing Care/Medical Facility

Personal Use

Legal

Insurance

Other

If other, please explain:(Required)

Specific information to be released (check all that apply):(Required)

If Other, Please Explain:(Required)

Your initials are required to release the following information:(Required)

Mental Health Records (excluding psychotherapy notes)

Drug, Alcohol, or Substance Abuse Records

Genetic Information (including test results)

HIV/AIDS Test Results/Treatment

I understand that this Authorization is effective for a period of 90 days from the date of signature(Required)

Unless otherwise specified below. No time frame may exceed one year from the date of signature. I understand that I have the right to revoke this authorization at anytime by sending a written request to the entity/person I authorized to release the information. If applicable, specify other expiration date/event here:

Printed Name(Required)

First Last

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provides by Texas Health & Safety Code § 181.154 (c) and/or 45 C.F.R. § 164.502 (a) (l). l understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws. I also understand lam signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.

Signature(Required)

Date Signed(Required)