www.jenkinsobgyn.com - MEDICAL RECORDS REQUEST

MEDICAL RECORDS REQUEST

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I hereby authorize (Previous Doctor Information) :
Address

Street Address

Apartment #

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Phone Number:
Fax Number:
To furnish a copy of medical records, this may include information concerning the results and/or drug abuse, of the patient listed below upon making request. I hereby release you, our physicians and employees from liability for following this authorized release form.
TO: Jenkins Ob/Gyn and Reproductive Medicine,
23535 Kingsland Boulevard, Katy, Texas 77494
Phone: 855-346-8610
Fax: 281-347-2603

**PLEASE MAIL IF OVER 30 PAGES**

****THIS AUTHORIZATION IS VALID FOR 120 DAYS FROM THE DATE OF SIGNATURE ANY CHANGE IN AUTHORIZATION MUST BE IN WRITING****
Pap SmearOffice NotesLabsMammographyOperationPrenatal RecordAll
Patient Name :*

First NameMiddle NameLast Name
Date of Birth:

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Date
Home Address :

Street Address

Apartment #

CityState

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Phone Number:
Signature*
Date:

MonthDayYear
Date
This document or documents accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of the information is prohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to destroy the information after stated need has been fulfilled. If you are not the intended recipient, you are hereby notified that any disclosure, copying distribution, or action taken in reliance on the contents of these documents strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
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