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 that
this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health
care provider, the released information may no longer be protected by federal privacy regulations.

Provider/Person receiving the information:

DIGESTIVE & LIVER DISEASECONSULTANTS,PA
Dr's Reddy, Hamat, Chalasani, Ewelukwa & Otulana
275 Lantern Bend Drive Ste. 200
Houston, Texas 77090

Fax: 855-404-4345

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 a
copy 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