North Texas Infectious Diseases Consultants, PA 3409 Worth-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field at the top of the form. This identifies you as the patient authorizing the release of information.
3. Next, check one box to indicate whether you want to get records from or send records to a specific entity. Fill in the corresponding address and phone number for clarity.
4. Select the purpose for which you are requesting this information by checking one of the provided options: patient’s request, continued medical care, insurance, or other.
5. Indicate which specific health information you authorize for disclosure by checking all applicable boxes such as entire medical record, billing records, immunization information, office notes, and lab/radiology results.
6. Review the authorization statement regarding revocation and expiration. Ensure you understand your rights before signing.
7. Finally, sign and date the form at the bottom. Make sure to include your date of birth for verification purposes.

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