Authorization to disclose protected health information form

Patient Name:
Date of Birth:

Home Address:

Purpose of RequestContinuation of carePersonalLegalInsuranceOther

I 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.

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Select method of release:In personMail to home addressFax

Please select records to be released:

Sonogram reportFetal EchocardiogramNon-Stress Test resultsGenetic Counseling reportLaboratory result

Pediatric EchocardiogramDiabetic Education reportHealth & PhysicalOther

1. I understand that Texas allows fifteen (15) business days to process request.

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2. I understand this authorization is voluntary, and the disclosure is made at my request.

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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.

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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
authorization

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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 above

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6. I hereby release Fetal Care Consultants, LLC from any and all legal liability that may rise from the release of
this information

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Patient/Legal Guardian Signature

Legal Guardian Name

Date

To 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 D1190

Phone: (972) 566-5600; Fax: (972) 566-5680

The global outbreak and spread of COVID-19 is affecting each of us. At Fetal Care Center Dallas, we are focused on its unique impact on our patients. The safety and well-being of our patients — moms, cardiac and pediatric surgery kids, and unborn children — remain our highest priority.

To keep our patients and staff safe and in alignment with hospital and government mandates, we have made the following changes to our visitor guidelines:

We allow one visitor over the age of 18 to accompany pregnant patients.
We allow two parents/guardians to accompany pediatric patients.
We do not allow any additional visitors or children in our offices at any location.
While we have elected to make masks optional at this time, the hospitals we partner with may require patients to wear masks while in their buildings. Should changes be made per national guidelines, we will update patients directly prior to their visit.

As always, we'll make clinical decisions regarding follow-up appointments on an individual patient basis. Please stay in close touch with us and be assured that our physicians want their patients to come to them as needed with questions and concerns. Working together, we will make it through this challenging time.

Our Dallas office has moved to 7777 Forest Lane, Building D, 11th Floor, Suite 1190

Fetal Care Consultants, LLC. 7777 Forest Lane, Suite D1190

Phone: (972) 566-5600; Fax: (972) 566-5680