Authorization to disclose protected health information form

    Purpose of Request

    I authorize Fetal Care Consultants, LLC to release to:

    Date of service range (month/year):

    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.

    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
    this information

    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