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I request and authorize:

(****Address and Phone must be complete to expedite your request****)

To release healthcare information on the patient named above to:

Beaumont Internal Medicine & Geriatric Associates
755 N. 11th Street Suite P-5200
Beaumont, TX 77702
The following information is to be disclosed:
I understand that my medical record may contain reports, test results & notes that only a physician can interpret. I understand I should contact my physician regarding the entries made in my medical record to prevent my misunderstanding the information. I will not hold Beaumont Internal Medicine & Geriatric Associates liable for any misinterpretation of the information in my medical record as a result of not consulting my physician for his/her interpretation.

I understand the information in my record may include information relating to sexually transmitted diseases, acquired immunodeficiency (HIV). It may also include information about behavioral or mental health services or treatment for alcohol and drug abuse.

Right to revoke: I understand I have the right to revoke this authorization at any time. I understand my revocation must be in writing. I understand the revocation will not apply to information already released.

Other rights: I understand I may inspect or obtain a copy of the information to be used or disclosed.

Expiration: Unless otherwise revoked, this authorization will expire on the following date, event, or condition. (If an expiration date, event or condition is not specified, this authorization will expire in 6 months).

This will be considered as your signature.

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