Txgidocs
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 
Acc Number 
Organization providing the information:
Provider/Person receiving the information:
DIGESTIVE & LIVER DISEASE CONSULTANTS, P.A.
Name 
275 Lantern Bend Suite 200 Houston, Texas 77090
Address 
281-440-0101 Ext 1208
Phone 
Email: MEDICALRECORDS@GIMED.NET
Fax 
PLEASE
 mail 
 fax my records or 
 i will pick up at lantern bend office 
(REQUIRED) Specific description of the information (including date(s) of healthcare) to be disclosed: 
Section B: Must be completed ONLY if a patient, health plan or health care provider has requested the authorization
1. The patient, health plan or health care provider must complete the following:
a What is the purpose of the use or disclosure 
b Will the patient 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 yes 
 no 
2. The patient or the patient’s representative must read and initial the following statements:
a. I understand that my health care and the payment for my health care will not be affected if I do not sign this form .
Initials 
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:
1 I understand that this authorization will expire on 
Initialss 
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 affect on any actions taken by the providing organization before they received the revocation.
Initial 
Printed name of patient’s legal representative (Legal Documentation Required): 
Signature of patient or patient’s legal representative
Date 
Relationship to the patient: 
                                               *** YOU MAY REFUSE TO SIGN THIS AUTHORIZATION *** 
This form may be used to release information for treatment or payment except when the information to be released is psychotherapy notes or certain research information. 
 