9022 Culebra Road Suite 112
San Antonio, TX 78251

Phone: 210-802-3777
Fax: 210-819-4555
info@WestoverHillsPrimaryCare.com
www.WestoverHillsPrimaryCare.com

MEDICAL RECORDS RELEASE AUTHORIZATION

1. Patient Information

Last Name *

First Name *

M.I.

Date of Birth *

I authorize the previous office named below to release my medical records to the practice identified in section 3.

2. Previous Office (records source)

Office / Provider Name *

Phone

Fax

3. Records To Be Disclosed To

Westover Hills Primary Care
Contact Person: Fabiola Mejia
Attn: Medical Records
Phone / Fax: 210-802-3777 / 210-819-4555

4. Purpose

Medical Record Transfer to a Primary Care Provider.

Printed Name *

Signature *

Use mouse, finger, or stylus to sign above.

Date *

Representative authority (if signed on behalf of patient)

By signing electronically, I acknowledge that this electronic signature is legally binding and has the same validity and effect as my handwritten ink signature. *