Authorization to Use or Disclose Protected Health Information

Patient First Name

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Patient Last Name

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Date of Birth

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Address:

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Phone:

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Provider's Name

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Address:

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Phone:

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Fax:

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The records I am requesting are from the following dates:

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I am requesting these records because:

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Physician Notes

Lab Results

X-ray Reports

X-ray Discs

MRI Reports

Cardiac Reports

Complete Records

Others

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Sensitive information : I understand that the information in my record may include Personal Health Information (PHI) of all manners.

Redisclosure: I hereby authorize r. Latika Hinduja and office staff to release all the above information to me or to the provider listed above.

Patient (or Legal Guardian / Parent) Signature

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