Authorization of
Records Release

Please fill out the electronic form below.
If you don’t want to fill out this form electronically, click here to print a PDF version and fill it out prior to your appointment.
Thank you.

PATIENT PROFILE

First Name

M.I.

Last Name

Date of Birth (mm-dd-yyyy)

Authorization and Release Information

I hereby authorize:

Physician 1 Name

Address

Phone Number

Fax Number

Add

Physician 2 Name

Address

Phone Number

Fax Number

Add

Physician 3 Name

Address

Phone Number

Fax Number

Add

Physician 4 Name

Address

Phone Number

Fax Number

To release information to:

Vanguard Inpatient Physicians

Arusha Bavare, M.D.

4645 Sweetwater Blvd, Suite 200, Sugar Land, TX 77479

4650 FM-1960 Rd West, Suite 101, Houston, TX 77069

Phone: 281-565-1112

Fax: 281-565-1102

Purpose of Disclosure

Continuing Medical Care

No

Legal

No

Insurance Claim/Payment

No

Other (specify)

No

Information to be released

H & P/ Initial Evaluation

No

Consult Notes

No

Progress Notes

No

Discharge Summary

No

Orders

No

Imaging Reports

No

Lab/Pathology Reports

No

Diagnostic Procedure Reports

No

Other (specify contents and dates)

No

I specifically authorize the release of information relating to:

Substance Abuse (including alcohol/drug use)

No

Behavioral Health

No

HIV related information (AIDS related testing)

No

Date

Signature of Patient or Personal Representative

Acknowledgement of Understanding:

I understand the expiration date of this authorization form is 1 year from the date signed.

I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations.

I understand by not authorizing this use or disclosure of information, there will be no conditions placed on my health care or payment for my health care.

I understand that I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records.

Date

Signature of Patient or Personal Representative

When you submit, your form will be sent to a HIPAA secure account.