Patient Name: Date of Birth: Home Address: Purpose of RequestContinuation of carePersonalLegalInsuranceOtherI authorize Fetal Care Consultants, LLC to release to: Name/Facility: Phone: Address: Fax:Date of service range (month/year): From To If released to self, I understand there is a fee of $25 for the first 20 pages plus $0.50/page thereafter paid to Fetal Care Consultants, LLC. I understand that this fee must be paid prior to receiving records by calling the office to make the payment after submitting this form.Initial here Select method of release:In personMail to home addressFaxPlease select records to be released:Sonogram reportFetal EchocardiogramNon-Stress Test resultsGenetic Counseling reportLaboratory resultPediatric EchocardiogramDiabetic Education reportHealth & PhysicalOther1. I understand that Texas allows fifteen (15) business days to process request.Initial here 2. I understand this authorization is voluntary, and the disclosure is made at my request.Initial here 3. If the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.Initial here 4. I have a right to revoke this authorization at any time, and if I revoke this authorization, I must do so in writing. Any revocation will not apply to information that has already been released in response to this authorizationInitial here 5. I request this authorization to expire on or 60 days from the date signed below and covers only treatment for the date(s) specified aboveInitial here 6. I hereby release Fetal Care Consultants, LLC from any and all legal liability that may rise from the release of this informationInitial here Patient/Legal Guardian Signature Legal Guardian Name DateTo the party receiving this information: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulation prohibits you from making any further disclosure of it without specific written consent from the patient. A general authorization for release of medical records or other information is not sufficient for this purpose.Fetal Care Consultants, LLC. 7777 Forest Lane, Suite D11906>Phone: (972) 566-5600; Fax: (972) 566-5680Δ