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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.
Patient Name 
Date of Birth 
ID Number 
Organization providing the information
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Organization receiving the information
DIGESTIVE & LIVER DISEASECONSULTANTS,PA
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Dr's Reddy, Hamat, Chalasani, Ewelukwa & Otulana
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275 Lantern Bend Drive Ste. 200
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Houston, Texas 77090
Phone: 
Fax: 855-404-4345
Specific description of the information (including date(s) of healthcare) to be disclosed:
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Text Field 
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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:
a. What is the purpose of the use or disclosure?
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b. Will the health plan or health care provider requesting the authorization receive financial or in-kind compensation in
exchange for using or disclosing the health information described above?