This form is a consent to the release of medical history. The patient authorizes the release of his/her medical history to the specified party within the consent release form. The form also provides that all prior authorizations are cancelled.
Consent Form For Release Of Information In Bexar
State:
Multi-State
County:
Bexar
Control #:
US-00460
Format:
Word;
Rich Text
Instant download
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Consent it is my responsibility to state this in writing. The patient or patient's legally appointed representative must complete the rest of the form.Please review the information below and sign and date where indicated. Adults: complete the form titled Adult Consent Form (F11-13366) (PDF). Please download and fill out any of these necessary forms to obtain your medical records. Authorization for Release of Behavioral Health Records. View the form in English. Release of Information. By completing this form, you are submitting a written request for access to the PHI of the designated individual. Edit, sign, and share bexar county district clerk online.