Authorization for Release of Information
Section A: Must be completed for ALL authorizations
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand thatthis authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
Provider/Person receiving the information:
DIGESTIVE & LIVER DISEASECONSULTANTS,PADr's Reddy, Hamat, Chalasani, Ewelukwa & Otulana275 Lantern Bend Drive Ste. 200Houston, Texas 77090
Section B: Must be completed ONLY if a health plan or health care provider has requested the authorization
1. The health plan or health care provider must complete the following:
2. The patient or the patient’s representative must read and initial the following statements:
a. I understand that my health care and the paymentfor my health care will not be affected if I do not sign this form.
b. I understand that I may see and copy the information described on this form if I ask for it, and that I will receive acopy of this form after I sign it.
Section C: Must be completed for ALL authorizations:
The patient or the patient’s representative must read and initial the following statements:
2. I understand that I may revoke this authorization at any time by notifying the providing organization in writing. Should I do so, this action will not have any effect on any actions taken by the providing organization before they received the revocation.
*** YOU MAY REFUSE TO SIGN THIS AUTHORIZATION ***
This form may not be used to release information for treatment or payment
except when the information to be released is psychotherapy notes or certain research information.
Alternate Fax: 281-866-9377
Requesting Provider : GNR / HBH / RC / OE / OO