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Medical Records Release Form

Please fill out the form below or use Microsoft Word to open and print.
You may fax or mail to our office.
Tyler Internal Medicine 1910 Roseland Blvd. Tyler, TX 75701 FAX (903)533-0441


Medical Records Release Form All fields are required. This form authorizes you to provide a copy, summary or narrative of your medical records or otherwise release confidential information.

HIV/AIDS: I consent to the release of any positive or negative test results for AIDS or HIV infection, antibodies to AIDS of infection with any other causative agent of AIDS with the rest of my medical records.

Release from the following person(s):

Release to the following person(s):


NOTICE TO RECIPIENTS OF INFORMATION: This information has been disclosed to you from records whose confidentiality is protected by Federal Law.  Federal regulations (42, CFR pat 2) prohibit you or your organization from making any further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulation.  A general authorization or the release of medical or other information is NOT sufficient for this purpose.  The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client/patient.
MENTAL HEALTH: This information is released subject to the “Confidentiality” provisions of TX.H.S. Code 611 and Texas Rules of Evidence (Civil/Criminal) Rules 510.
DRUG/ALCOHOL: This information is released subject to the “Confidentiality” provisions of 42 U.S. C 290dd-2; 42 C.F.R.>Part 2.
MR: This information is released subject to “confidentiality” provisions of the Mentally Retarded Person Act of 1977, and TX>H.S. Code CH 595.
HIV/AIDS: This information is released subject to “Confidentiality” provisions of the Communicable Disease Prevention Control Act of 1987, and as amended TX.H.S. Code 81.001: the Human Immunodeficiency Virus Services Act, TX.H.S. Code 85.001.

I understand that you will provide this information within 15 days of receipt of this request and that a FEE for preparing this information may be charged according to the rulings set for by the Texas State Board of Medical Examiners and the Texas Medical Association.

Electronic signature

Tyler Internal Medicine requires that you certify your application by submitting an electronic signature. To certify your application, read the text below and provide an electronic signature (type your name) and click Submit. I certify that all the information within this form is accurate and true.