AUTHORIZATION TO RELEASE MEDICAL INFORMATIONPlease enable JavaScript in your browser to complete this form.AUTHORIZATION TO RELEASE MEDICAL INFORMATION *FirstLastFirstLast5915 Silver Springs Dr. Building 3 Suite-A, El Paso TX 79912 Phone: (915) 228-3080 Fax: (915) 226-0076I request and authorize _________________ to release healthcare information of the patient named above to: Patricia Lopez Po, MD || 5915 Silver Springs Dr Building 3 Suite-A || El Paso, TX || 79912 *This request and authorization apply to: *All Healthcare InformationHealthcare information relating to the following treatment, condition, or dates:__________OtherIf you selected "All Healthcare Information", ignore the next two fields. Healthcare information relating to the following treatment, condition, or dates: __________If you selected "Healthcare information relating to..." please fill this out. If you selected "All Healthcare Information" you can ignore this field.Other:If you selected "Other" please fill this out. If you selected "All Healtchare Information" you can ignore this field.I authorize the release of all healthcare information relating to HIV/AIDS testing, sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use. *YESNOI understand I have the right to revoke this authorization by providing a written request to do so to the above-named physician or organization. I understand that the revocation will not apply to information that has been already released. *YESNOPatient Signature & Date *FirstLastEmail *Submit
