Authorization to Release Information form

    I hereby authorize the party below to disclose my individual identifiable health information as described below, which may include information concerning communicable diseases such as HIV, AIDS, chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such information. I understand that this authorization is voluntary, and I may refuse to sign this authorization. I further understand that health care and the payment of my health care will not be affected if I do not sign this form.

    Authorization is given by the undersigned to release the information specified below

    Description of Information to be released
    Entire RecordUltrasound ReportsPrenatal RecordOperative ReportRadiology Films/Reports

    The Information is requested for the following Purpose:
    Continuation of Medical CareTransfer of CarePatient’s RequestOther (Specify)

    I understand that if the recipient authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal and state privacy regulations

    I understand that this authorization will expire by law 180 days from the date of this authorization unless I otherwise specify. I desire this authorization to be in effect until

    I understand that this authorization can be revoked by me at any time by submitting a written request. I understand that revocation will not apply if information has already been released

    Fetal Care Consultants, LLC. 7777 Forest Lane, Suite D1190
    Phone: (972) 566-5600; Fax: (972) 566-5680