In compliance with section 102.006 Texas occupation code in connection with my informed consent and personal choice of doctors and facility solely based on the quality and safety of care. Reputation of patient satisfaction.and my knowledge in my decision-making in exercising my rights with respect to the in-network or out of network coverage and cast sharing. my attending doctors and/or clinic have disclosed ti me at the time of initial contact and at the time of referral with respect to the choice of a doctor or facility solely in the interest if my healthcare quality and safety. as a result of my informed consent and personal choice if doctors and/or facility; A his/her affiliation. if any. With the doctor or facility fir whom the patient is refereed and that he/she will receive, directly or indirectly. Remuneration fir referring upon my such request and exercising my rights of freedom of choice for the provider and facility under the in network or out of network coverage as provided by my health plan. In compliance with all applicable federal and state laws, Medicare, ERISA, PPACA. and Section 102.006 of Texas Occupation Code.

    Doctor or Facility with affiliation and remuneration:

    Memorial Hermann Hoispital - TMC
    Humble Surgical Hospital
    Memorial Hermann Hospital - Northeast
    Vital Heart & Vein, PLLC - CT Lab
    Kingwood Medical Center
    Humble Dreams Sleep Center

    I certify that my attending physician(s)_has made referrals to participating providers or the other non-participating providers or entities based only on the needs of my individual healthcare, the medical community standard of care and my informed choice for quality and safety of the care that i will be expecting and receiving. and for a provider's professional reputation and patient satisfaction in order to provide me with the quality and affordable healthcare that i personally expected under my health plan for out-of-network or in-network coverage.

    I have read and fully understand this Disclosure and Authorisation Form. I here by authorise this referral to non-participating and out-of-network provider(s) or entities as named above.

    Patient Name(Print) :