Purpose of Request
I authorize Fetal Care Consultants, LLC to release to:
Date of service range (month/year):
If release to self, select method of release:
Please select records to be released:
1. I understand that Texas allows fifteen (15) business days to process request.
2. I understand this authorization is voluntary, and the disclosure is made at my request.
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.
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
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
6. I hereby release Fetal Care Consultants, LLC from any and all legal liability that may rise from the release of
7. If released to self, I understand there is a fee of $25 paid to Fetal Care Consultants, LLC.
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 D11906>
Phone: (972) 566-5600; Fax: (972) 566-5680