AUTHORIZATION FOR RELEASE OF CONFIDENTIAL MEDICAL INFORMATION

Instruction for patients: Please complete this form, then print, initial and sign all required areas. You will then need to fax or mail the completed and signed form to the hospital's medical records department where you had your tubal ligation performed or to the doctor's office who performed the surgery.
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AUTHORIZATION FOR RELEASE OF CONFIDENTIAL MEDICAL INFORMATION

I

Patient Name

Authorize

Name of hospital or doctor's office

To release a copy of my OPERATIVE report from my TUBAL LIGATION and a copy of my PATHOLOGY REPORT from my TUBAL LIGATION, ALONG WITH THIS RECORDS RELEASE REQUEST FORM to:

Bernard L. Rosenfeld Tubal Reversal Specialist, M.D., Ph.D.

FAX#: 713-790-0527

Or by mail to:
7400 Fannin Street | Suite 910M
Houston, Texas 77054

Note to Hospital/Doctor's Office: Please fax or mail your records with a copy of this Records Release Request Form. The purpose of the requested disclosure is to allow Dr. Rosenfeld to review my medical records in order to determine if tubal reparative surgery will be possible.

The date of my Tubal Ligation was*

MonthDayYear

Name at the time of your tubal ligation*

Full Name*

Date of Birth*

MonthDayYear

Social Security Number*

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone*

With area code

Cell Phone*

With area code

E-mail

_________ (Initial) I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to this authorization. I Understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department.

_________ (Initial) I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign, and future treatment, payment, or eligibility for benefits will not be based on whether or not I provide authorization for the requested use or disclosure. I understand that the recipient may be prohibited from disclosing substance abuse information. I understand that I may inspect or copy the information to be disclosed (with reasonable charge).

_________ (Initial) I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of the information and is no longer protected by federal confidentiality laws. Unless otherwise revoked, this authorization will expire six months from the date of the signature listed below.

Patients Signature __________________________ Date ________________