Medical Records Release Authorization Form HomeMedical Records Release Authorization Form Authorization for Release of Medical Records from the Veterinary Medical Teaching Hospital I authorize the following protected health information to be released from the medical record of: Requestor's InformationPatient's Name(Required) Owner's Name(Required) First Middle Last Email(Required) Phone(Required)FaxAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Release Records To:Name of Owner, Veterinarian, etc.(Required) First Middle Last Clinic, Hospital, etc. Email(Required) Phone(Required)FaxAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Records to be Released► NOTE: If specific dates to be released are not provided, all records in the category marked will be released.To be Released(Required) Entire Record Xray Copies/CD Vaccinations Necropsy Report Discharge Instructions (includes lab test results, radiographic reading, diagnosis, etc.) Select AllDate Service Began Month Day Year Date Service Ended Month Day Year How should the records be delivered?(Required) Call me when my records are ready for pick up. Mail my records to the address provided. Fax my records to the number provided. Email my records to the email address provided. Reason for Release of Records(Required) Further Medical Care Owner’s Request Insurance Legal Investigation Other Other Consent to Release Medical RecordsConsent(Required) I agree.Texas A&M University, the School of Veterinary Medicine & Biomedical Sciences, the Veterinary Medical Teaching Hosptial, the Large Animal Teaching Hospital, and the Small Animal Teaching Hospital are hereby released from all legal liability that may arise from the improper handling of the requested and released information.Name of Owner or Legal Representative Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
