PATIENT AUTHORIZATION FORM TO REQUEST CONFIDENTIAL HEALTHCARE INFORMATION

I authorize Rheumatology Associates to use and/or REQUEST certain protected health information (PHI) about me from:

    PATIENT/GUARDIAN TO BE PROVIDED WITH A SIGNED COPY OF AUTHORIZATION

    Dallas   ·   Arlington  ·   Duncanville  ·   Flower Mound  ·   Frisco  ·  Grapevine  ·   Irving   ·   North Richland Hills   ·   Plano   ·   Rockwall