TEXAS CHILD NEUROLOGY, LLP

1708 COIT RD.,  SUITE 150

PLANO, TEXAS 75075

972-769-9000  phone    972-769-0035  fax

AUTHORIZATION FOR RELEASE OF INFORMATION

PATIENT NAME: ______________________________________________________ DOB: _________________________

I certify that I am the Parent and / or Legal Guardian of the above named patient, and hereby request:

Physician or Clinic Name:   ________________________________________________________________________________

Address                                _________________________________________________________________________________

                                               _________________________________________________________________________________

Phone Number                    ______________________________     Fax Number    ________________________________

Send all medical records to:    

                              Texas Child Neurology, LLP

                              1708 Coit Rd.., Suite 150

                              Plano, Texas 75075

Information to be released:

Discharge Summary  _________            Operative Report                                                                 __________

History & Physical    _________             Lab, X-rays, Pathology, EKG, EEG, CT, MRI Scans       __________

Progress Notes        _________              Outpatient Clinic Visits                                                       __________

This information is released for CONTINUITY OF CARE and that purpose only (any other use is forbidden).

                _______________________________________________________________

TEXAS CHILD NEUROLOGY, LLP is hereby released from legal responsibility or liability for the release of the records to the extent indicated and authorized herein.  I also understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on (e.g., probation, paroling, etc.) and that in any event this authorization expires automatically as described below. This authorization will expire  ONE YEAR from the date of my signature or as otherwise specified by date, event or condition as follows.

_________________________________________________________        _______________________

      Signature of Parent / Guardian                                                                       Date

__________________________________________________________      _______________________

      Witness                                                                                                         Date

PROHIBITION OF REDISCLOSURE: This information has been disclosed to your from records whose confidentiality is protected by both state and federal law.  Federal regulation (42 CFR, Part 2) prohibits you from making any further disclosure of this information except with the specific written consent of patient.  A general authorization for the release of information if held by another party is not sufficient for this purpose.  Federal regulations state that any person who violates any provision of this law shall be fined not more that $500.00 in the case of a first offense, and not more than $5,000.00 in the case of each subsequent offense.