[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288954-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-288954-en":127},{"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":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","medical-records-release-authorization-form-plano-office","Medical Records Release Authorization Form - Plano Office","","This Medical Records Release Authorization Form is a formal document utilized by the medical practice of Dr. Lewis J. Frazee, Dr. Ellen Ngo, and Dr. Gina Pham, with offices in Plano and Lewisville, Texas. The form facilitates the legal transfer of patient health information between healthcare providers or designated parties. It includes sections for identifying patient details, specifying the recipient of the medical records, and selecting the scope of information to be released, such as testing images, medical history, or HIV-related data. The document concludes with an authorization section requiring the patient's signature and date to ensure HIPAA-compliant processing of sensitive health records. It serves as an essential administrative tool for maintaining organized patient files and ensuring seamless communication between different medical facilities while upholding patient privacy standards and legal requirements for record requests.",{"@graph":14,"@context":73},[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/medical-records-release-authorization-form-plano-office/288954/",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/medical-records-release-authorization-form-plano-office/288954.png","ImageObject",442,249,{"name":42,"@type":43},"Jacob","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",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required to process a records release?","Question",{"text":63,"@type":64},"To process the release, the form requires the patient's name, date of birth, the names and contact information of both the releasing and receiving parties, and the patient's signature.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Can patients choose to exclude sensitive information from their records release?",{"text":68,"@type":64},"Yes, the form specifically provides options to include or exclude HIV information, and allows patients to select if they want to include testing images, results, or contact lens records.",{"name":70,"@type":61,"acceptedAnswer":71},"Where are the primary offices of these physicians located?",{"text":72,"@type":64},"The medical practice has two office locations: the Plano office at 4100 West 15th Street, Suite 210, Plano, Texas 75093, and the Lewisville office at 751 Hebron Parkway, Suite 230, Lewisville, Texas 75057.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},288954,1789634281,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":4},962084931830,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","Plano Office Lewis J. Frazee, M.D.  \n4100 West 15th Street-Suite 210 Ellen Ngo, M.D.  \nPlano, Texas 75093 Gina Pham, M.D.  \nLewisville Office Phone: 972-867-7777  \n751 Hebron Parkway – Suite 230 Fax: 972-519-1679 Lewisville, Texas 75057  \nMedical Records Release Authorization Form  \nPatient’s Name:   DOB:    \nRelease: From  To   \nDoctors Name:    \nAddress:    \nCity/State/Zip:    \nTelephone number:   Fax number:    \nMedical Records  \nInclude testing images/results  \nInclude HIV information (if this applies)  \nDo not include HIV information (if this applies) Contact lens records  \nSummary of medical history  \nReason for this records release:    \nSignature of patient or responsible party:  \n   Date:","cbCaivmO1GMaCSCz","https://ap.wps.com/l/cbCaivmO1GMaCSCz","pdf",67067,"English","# Medical Records Release Authorization Form\n## Facility and Provider Information\n## Patient Identification and Release Details\n## Medical Records Scope and Authorization","[{\"question\":\"What information is required to process a records release?\",\"answer\":\"To process the release, the form requires the patient's name, date of birth, the names and contact information of both the releasing and receiving parties, and the patient's signature.\"},{\"question\":\"Can patients choose to exclude sensitive information from their records release?\",\"answer\":\"Yes, the form specifically provides options to include or exclude HIV information, and allows patients to select if they want to include testing images, results, or contact lens records.\"},{\"question\":\"Where are the primary offices of these physicians located?\",\"answer\":\"The medical practice has two office locations: the Plano office at 4100 West 15th Street, Suite 210, Plano, Texas 75093, and the Lewisville office at 751 Hebron Parkway, Suite 230, Lewisville, Texas 75057.\"}]","Medical Records Release Authorization Form - Plano Office | PDF"]