[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288948-105":3,"detail-sidebar-cat-1-en-105":73,"doc-detail-288948-en":118},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":66,"head_meta":68,"extra_data":70,"updated_unix":72},105,"en","conroe-family-physicians-medical-records-release-authorization-form","Conroe Family Physicians - Medical Records Release Authorization Form","","This document serves as an official Medical Records Release Authorization Form for Conroe Family Physicians. It facilitates the secure transfer of patient health information, including lab results, radiology reports, and consultation notes, between healthcare providers such as Conroe Family Medicine or Kelsey Seybold and the Conroe Family Physicians practice. The form includes necessary legal provisions for HIPAA-compliant disclosure, specific consent for sensitive HIV/AIDS-related information, and clearly defined expiration terms for the authorization. It is designed to ensure continuity of patient care and treatment by allowing seamless access to comprehensive medical histories. The form requires the patient or their personal representative to sign and date the agreement to authorize the transfer, while also providing instructions for patients who wish to revoke their authorization in writing. By formalizing this process, the medical clinic maintains strict adherence to federal privacy regulations while prioritizing efficient information management.",{"@graph":14,"@context":65},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/conroe-family-physicians-medical-records-release-authorization-form/288948/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/conroe-family-physicians-medical-records-release-authorization-form/288948.png","ImageObject",442,249,{"name":42,"@type":43},"Jake","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59],{"name":60,"@type":61,"acceptedAnswer":62},"How long does this authorization remain in effect?","Question",{"text":63,"@type":64},"The authorization is in force and effective for 60 days from the date signed by the patient or their personal representative.","Answer","https://schema.org",{"og:url":32,"og:type":67,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":69,"canonical":32},"index,follow",{"doc_id":71,"site_id":7},288948,1789634272,{"code":4,"msg":74,"data":75},"success",[76,80,85,90,95,100,104,109,114],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":77,"show_sort_weight":78,"slug":79},"Presentations",90,"presentations",{"id":81,"doc_module":22,"doc_module_name":25,"category_name":82,"show_sort_weight":83,"slug":84},12,"Resumes",80,"resumes",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":87,"show_sort_weight":88,"slug":89},14,"Invoices",70,"invoices",{"id":91,"doc_module":22,"doc_module_name":25,"category_name":92,"show_sort_weight":93,"slug":94},15,"Posters",60,"posters",{"id":96,"doc_module":22,"doc_module_name":25,"category_name":97,"show_sort_weight":98,"slug":99},16,"Social Media",50,"social-media",{"id":101,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":102,"slug":103},17,40,"forms",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},18,"Letters",30,"letters",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},21,"Paper Templates",5,"papers-templates",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":116,"show_sort_weight":4,"slug":117},158,"General","general-158",{"code":4,"msg":74,"data":119},{"doc_id":71,"user_id":120,"nickname":42,"user_avatar":121,"doc_module":22,"category_id":101,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":127,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":12,"update_tm":72,"read_time":4},962084928904,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","MEDICAL RECORDS RELEASE AUTHORIZATION FORM  \nPatient Name:  DOB:   \nRelease Records From: Conroe Family Medicine/Kelsey Seybold 690 S Loop 336 West, STE 222 , Conroe, TX 77304 Phone: 936-756-6661 Fax: 936-756-6681  \nRelease Records To: Conroe Family Physicians  \nDr. Chapman, Dr. Hinds-Campa, Dr. Sheih  \n690 S. Loop 336 West, STE 140, Conroe, Texas 77304  \nPhone: 936-523-7041 Fax: 936-271-2557  \nThe health information you may release subject to this authorization is as follows (􀀹):  \n All medical records   Labs   Radiology   Consult Notes  \n  From service date(s):  to    \nHIV/AIDS: I consent to the release of any positive or negative test results for AIDS or HIV infection, antibodies to AIDS, or infection with any other causative agents of AIDS with the rest of my medical records. Initial:   Date:    \nThe purpose for this release of information is for patient care and treatment. This authorization shall be in force and effective for 60 DAYS from the date below. By signing this form, I authorize you to use and disclose the protected health information. I understand that I have the right to revoke this authorization, in writing, at any time by sending a written notification to Conroe Family Physicians at the address below. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations.  \nSignature of Patient or Personal Representative Date","cbCail40cJM6k4JP","https://ap.wps.com/l/cbCail40cJM6k4JP","pdf",50816,"English","# Patient Information and Authorization Details\n## Medical Records Release Authorization\n## HIV/AIDS Consent and Revocation Rights","[{\"question\":\"How long does this authorization remain in effect?\",\"answer\":\"The authorization is in force and effective for 60 days from the date signed by the patient or their personal representative.\"}]","Conroe Family Physicians - Medical Records Release Authorization Form | PDF"]