Auth Release Records To Us - The Heartbeat Clinic

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Full Name:

Date of Birth:

Previous Name:

Social Security #:

I request and authorize to release healthcare information of the patient named above
from:

Full Name:

Full Address:

Phone (For SMS if appicable):

Fax:

Email:

to:

Name: The Heartbeat Clinic – Dr. Amer Suleman
Address: 4541 Medical Center Dr. #800 McKinney, TX 75069
Phone: (214) 504-9942
Fax: (214) 504-9940
Email: info@thbc.us

The request and authorization applies to:

Healthcare information relating to the following treatments, conditions, and/or dates:

All healthcare information

Date ranges (if applicable) From:

Other:

I authorize the release of my records to the person(s) listed above.

Yes

Patient Signature:

Date:

Witness Signature:

Date:

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED