Authorization To Release Health Care Information Home / Authorization To Release Health Care Information Patient's Name DOB SSN Previous Name I request and authorised to release health care information of the paitent name above (by mail or fax) to Vital Heart & Vein, PLLC: 6400 Fannin, Ste, 2210-B, Houston, TX 7703018955 Memorial Dr. N., Ste 580 & 250. Humble. Tx7733822999 US Hwy. 59. Ste. 210. Kingwood. TX 7733910907 Memorial Hermann Dr., Ste. 370, Pearland. TX 77584 This request and authorization applies to: Health care information relating to the following treatment, condition, or dates of treatment All health care informationOthers: I understand that my express consent is required to release any health care information related to testing diagonals, and /or treatment for HIV (AIDS virus). Sexually transmitted disease. Pregnancy, psychiatric disorder /mental health, or drug and/or alcohol use. If i have been tested, diagnosed, or treated fir HIV (AIDS virus), Sexually transmitted disease. Pregnancy, psychiatric disorder /mental health, or drug and/or alcohol use. you are specifically authorised to release all health care information relating to such diagnose. testing or treatment. I hereby authorise Vital Heart & Vein to release any or all information acquired int the course of my examination and/or treatment. I understand that this may include the release of any medical or other information required in the processing of claims for payment. I also authorise the release of information to another physician or health care facility to which the patient may be transferred or referred.
