Lone Star Physicians Group, P

Authorization to Relea= se Medical Information

I AUTHORIZE:
From:	To: Iresh Kumar, MD, FAAP
(Child’s physician/Clinic)
Address:	PO Box 1480=
City: &nbs= p; &= nbsp; &nbs= p; &nbs= p; State Zip	Frisco, TX 75034
Phone:	Phone: 214-705-= 9696
Fax:	Fax: 214-705-96= 97

Child’s Name:	Date of Birth: &nbs= p; / &nbs= p; / =
INFORMATION TO BE RELEASED: (Check all applicable)
¨ Complete Record	¨ All Progress Notes	¨ Laboratory Reports	¨ Radiology Reports
¨ Immunization Record	¨ Allergy Records	□ Consultations<= /p>	¨ Other:
= &nb= sp; = &nb= sp; = &nb= sp;
RECORDS FROM THE TIME PERIOD: &nbs= p; / / &nbs= p; through &nbs= p; / /
PURPOSE OF DISCLOSURE: (Check applicable purpose)
= ¨ Continued Medical Care	= ¨ Payment of Insurance Claim	= ¨ Legal
= ¨ Personal	= ¨ Workers’ Compensation Claim	= ¨ Other:
♦I unders= tand that this authorization shall be valid for one year from the date below. I understand that I may revoke this consent at any time except to the extent that action has already been taken. &#= 9830; I understand that a reasonable fee may be cha= rged for duplication of records. An estimate of those charges will be provided upon request prior to duplication. ♦ The requestor may be provided with a copy of = this authorization.

Parent/Guardian signature	Date

Name of Parent/Guardian (Print)	Relationship to patient:
	□ Parent □ Guardian □ Legal custod= ian

SPECIAL AUTHORIZATION: Check applicable box(es) and sign immediately below. By signing below, I am authorizing the office to release any and all informa= tion regarding: = ¨ Alcohol &nbs= p; ¨ Drugs &nbs= p; ¨ Mental Health &nbs= p; ¨ Sexually Transmitted Diseases &nbs= p; = ¨ HIV/AIDS &nbs= p; Note: If this release pertains to alcohol, drug, or mental health information, please note that this information has been disclosed to you from records protected by federal confidentiality rules = (42 CFR part 2). The federal rules prohibit you fr= om making any further disclosure of this information unless additional furth= er disclosure is expressly permitted by written consent of the person to who= m it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug ab= use patient.
Parent/Guardian Signature	Date

For office use only: ________________________________________________________________= __________________________ MR# = &nb= sp; = Date = ; &n= bsp; = ; Initials of Staff Member Sending