Record Release Form

Hereford, Texas 79045

EXT. 3913


I hereby request and authorize Hereford Regional Medical Center to release the following information about:

I further understand that I may revoke this authorization at any time by notifying Hereford Regional Medical Center in writing, except to the extent that action has been taken in reliance on it. Unless earlier revoked, this authorization expires automatically 90 days from the date signed or 90 days after the latest H.R.M.C. visit or after all insurance or third party claims have been paid or satisfactorily resolved, whichever occurs last.

Release From Liability: I release and agree to hold harmless H.R.M.C. and it's agents, representatives, and employees from any and all liability associated with the release of confidential patient information in accord with this authorization. I understand that H.R.M.C. cannot be responsible for use or redisclosure of information by third parties.

To The Receiving Party Of This Information: This information has been disclosed to you for the sole purpose(s) stated in this authorization. Any other use of this information without the express written consent of the patient is prohibited. These records may be protected by federal regulation (42 C.F.R. Part 2)

I certify that this form has been fully explained to me, that I have read it or had it read to me*, and that I understand it's contents.