9022 Culebra Rd., Suite 112
San Antonio, TX 78251

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

AUTHORIZATION TO RELEASE MEDICAL RECORDS

1. Please RELEASE my medical information to:

Name of Physician, Hospital, or Self *

Phone # *

Fax #

Address

City

State

Zip

2. Patient Information:

Print Patient Name *

Date of Birth *

Phone #

Address

City

State

Zip

3. Purpose for Records Request:

Example: personal use, primary care physician, transferring care, insurance change, insurance purposes, 2nd opinion, referral

4. Please specify records to be disclosed by checking the appropriate box ***:

Most Recent Visit Notes

Most Recent Labs ONLY Include HIV/AIDS and sexually transmitted disease information: Yes No

Most Recent Imaging

All Records Include HIV/AIDS and sexually transmitted disease information: Yes No

5. Please note: Please allow 10 business days for your request to be processed.

I understand that the authorization for disclosure of records as detailed above, unless specifically limited by me in writing, will extend to all aspects of treatment provided. These records may include testing for all sexually transmitted diseases, AIDS, and hepatitis, as well as drug, alcohol and/or psychiatric information. Westover Hills Primary Care is hereby released from all legal responsibility or liability for the release of the above disclosure of information. I have the right to withdraw this authorization at any time and that such revocation must be in writing.

Print Name *

Signature *

Use mouse, finger, or stylus to sign above.

Date *

Staff Use Only: Completed by: ________ Reviewed: ________ Fax / Mail / Picked up