Authorization for Release of Patient Information

Patient

Patient name *

Other names used

Date of birth *

SSN (last 4 digits) *

This information is needed for

Choose one.

Reason *

Please specify

Authorize T & R Clinic to

Choose one.

Direction *

Provider or Organization

Provider or organization *

Address *

City, state & ZIP *

Phone

Fax

Records for dates of service

Choose one.

Date range *

From

Through

Information to be released or accessed

Check everything to release. For everything, check the first box only.

Records

All health information History / physical exam Immunization records Past / present medications Lab results Patient allergies Operative reports Consultation reports / progress notes Radiology reports & images Discharge summary Diagnostic test reports EKG / cardiology reports Pathology reports Billing information Other

Please specify

Signature

This authorization expires 90 days from signing unless you specify otherwise below.

Signature of patient or legal representative *

Date

Applied automatically.

If signed by a legal representative, relationship to patient

Specific expiration (date, event, or condition) — optional

Authorization received

Your signed authorization has been sent to our records team.

Welcoming patients in English, Spanish, and Vietnamese.

Call us Patient portal Get directions

Address

2919 Markum Drive
Fort Worth, TX 76117

Phone: (817) 831-0321
Fax: (817) 831-3211

Clinic hours

Mon–Thu: 8 a.m.–5 p.m. · Fri–Sat: 8 a.m.–12 p.m. · Sun: Closed

Lab hours

Mon–Thu: 7:30 a.m.–4:30 p.m. · Fri: 7:30 a.m.–11 a.m. · Sat–Sun: Closed

If this is a medical emergency, call 911.

Our Story Forms Contact Privacy