Please note that it is important to fill in all the fields before submitting. Thank you.

*Patient’s : Last name :		Middle name :		*First name :
*Your birthday :		Social security # :
*Address :	City State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip APT#
I authorize:	Howard B. Gerber, MD Craig F. Teller, MD Suneel Chilukuri, MD Kimberly Mullinax, MD Jennifer L. Maender, MD Rebecca G. Clark, MS, PA-C to (please check action): Release or Obtain
The following information from my medical records to or from (select one) :			Person / Facility:
Name :
Address :	City State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip APT#
Telephone # :	()---			Fax # :	()--
Please check all information to be released (may contain information regarding drug/ alcohol/ psychological/HIV/ AIDS and/ or communicable diseases) :
	History & Physical	Pathology Results / Slides		Operative Reports
	Progress Notes	Lab Results		Other (please specify)
This authorization covers medical care		from:		to
The purpose for release of information is:
	Personal Use	Legal Purposes		Insurance
	Medical Care	Social Security/ Disability		Other (please explain):

* I understand that this authorization is valid for 180 days from the date of signature. I also understand that I may revoke this authorization in writing at any time except to the extent that action has already been made before the receipt of revocation. Additionally, I understand that a fee for preparing and furnishing this information may be charged according to ruling set forth by the Texas State Board of Medical Examiners.

Authorization to FAX medical records: Yes    No

*Signature of Patient :		Date :
Signature of Parent/ Executor/ Legal Representative :		Phone # :	()--