Medical Records Authorization

[Style of Case]

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

TO ALL PHYSICIANS, PSYCHIATRISTS, PSYCHOLOGISTS, DENTISTS, CHIROPRACTORS, PHYSICAL THERAPISTS, COUNSELORS, HOSPITALS, CLINICS, LABORATORIES, AND OTHER HEALTH CARE PROVIDERS:

I, [name of person authorizing release], authorize [name of person/firm authorized to obtain records] or any of [his/her/its] representatives to obtain all information pertaining to my physical, medical, mental, psychiatric, and/or psychological condition and treatment by you. Such information includes, but is not limited to, x-rays, laboratory reports, all tests of any type, treatment for drug and/or alcohol abuse or addiction, correspondence, neuropsychological testing and evaluations, reports or documents from any other caregiver(s) during my treatment, diagnostic studies, nurses’ notes, progress notes, charts, clinical abstracts, prescriptions, and all other records pertaining to my condition, care, treatment, and prognosis thereof, including narrative reports of, or interviews regarding, your examination, findings, and opinions.

In accordance with Tex. Health & Safety Code § 241.154(a), please provide a copy of the medical information specified above to [name of person/firm authorized to obtain records] within fifteen (15) days of the date you receive this authorization or a photocopy thereof and payment of reasonable copying fees.

This authorization is to be used in connection with the above-captioned lawsuit filed by me. This authorization is subject to revocation at any time except to the extent that the person or entity which is to make the disclosure has already taken action in reliance on it. Under Texas law, a revocation is valid only if it is in writing, dated after the date of this authorization, and signed by me or my legally authorized representative. If not...