CONSENT TO RELEASE PROTECTED HEALTH INFORMATION

  
  

I, hereby authorize The following       Facilities:

NAME:      ADDRESS:      PHONE:      FAX:     

ATTN:      To disclose and release complete health record including, but not limited to, diagnoses, lab test / results, radiology, pathology, treatment plan, and billing records for all conditions of myself, release to:		  
 
 
  

PREMIER ONCOLOGY CONSULTANTS. P.A
9230 KATY FREEWAY, SUITE 410
SPRING VALLEY MEDICAL PLAZA
HOUSTON, TEXAS 77055
PHONE: 281-556-6622 (MAIN)
FAX: 281-647-7767 (CENTRAL)
          

PREMIER ONCOLOGY CONSULTANTS. P.A
18400 KATY FREEWAY, SUITE 320
HOUSTON METHODIST WEST- PRO BLDG #1
HOUSTON, TEXAS 77094
PHONE: 281-647-7766 (KATY)
FAX: 281-647-7767 (CENTRAL)
  
 
 
  
Heath Records Requested:




The information may be released or disclosed in printed and/or digital format. A photocopy of this assignment is to be considered as valid as the original until revoked in writing.		  
 
 
  


  Patients Name (or Representative)  





  Patients Signature (or Representative)  		          


  Patients DOB   





  Date  		  
 

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