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

    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.