Neuropathy & Neurotherapy Center of Dallas - AUTHORIZATION TO RELEASE INFORMATION/RECORDS

AUTHORIZATION TO RELEASE INFORMATION/RECORDS

I hereby authorize Neuropathy & Neurotherapy Center of Dallas and its staff to release any and all psychological, psychiatric, educational, drug and/or alcohol abuse or use, HIV and AIDS results and/or medical records and to discuss, either verbally or in writing, the records involving:

Patient Name: *

Date of Birth: *

Social Security: *

I authorize this release to apply to the following party (where and to whom you want the records to be sent):

Name: *

Address *

City: *

State: *

ZIP: *

Phone: *

FAX: *

Furthermore, in signing this release, I understand that this authorization to release records will remain in effect indefinitely unless I submit a written request sent by certified mail which instructs Neuropathy & Neurotherapy Center of Dallas. to terminate this release. A photocopy or facsimile of this document shall be deemed as being as valid as the original.

Authorized by: *

Date: * +

Signature: *

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Relationship to patient: *