‘Madhavan Pisharodi, M.D. Board Certified: Neurological Surgery Amuro A Lira, MPAS, P.A«C Carlos A Lira, AGPCNP-BC Panly Medicine Gerontology-C Anthorization for the release of Medical / Billing Records Maier Pater pom = Ole = 1A Hereby authorize Xora Real To release my records to VIP Ch be eo ae BATS Wi Ailtin Clon Bly Erovonswille Tx. 19626 _ Phove numb ARS? 850-4706 __Facnomber QS) BSO-9Y4 3 Infarmation to be released: © History and Physical © Operative report © Discharge summary © Progress note(s) dates: 9 Alfradiology repos © Alibilling records other: ___ 1. The above information, including hospital recards, AIDS/HIV test results, diagnosis, geatment and relate information any), is wleased for the following purposes only, Any other js forbidden, 2. The purpose of the requested disclosure 3. Madhavan Pisharodi, M.D. may not conditioa treatment, payment, enrollment or eligibility for benefits on whether the individual signs this authorization. 4. With respect £0 any mental health information which may be contained in the medical records, I hereby wave my/his/her right to the privileges of confidentiality. 5. Talso understand this authorization expires automatically ninety (90) days from the original dave. 6 Prohibition of re-disclorure: Federal rul-s, such as but not limited to HIPPA requirements as written by HHS, probibit further disclosure of this information unless disclosure ig expressly permitted by written consent of the person to whom it penains, 7. Potential for re-disclosure: | understand che potential exist where the information deseribed in this authorization could be fedisclosed by the recipient and ifthe information is re-disclosed, itis no longer procected by the privacy laws. 8, Fee to obcain Meclical records will be in accondance with the Texas Medical Records Board $__ 9. To Worker's Compensation and Department of labor patients: As per Texas Medical Boards Pules, Worker's ang department of labor patients are allowed an initial request of medical records free of charge. After the initia! request, patients will be charged te fee allowed by the Texas Medical Records Hoard Rules, 10, I have the right t revoke this authorization at any time by,cuntacting the privacy officer; such request must be made in swreng aa Pavients/ Authorize legal representative's rma au oe See Deda Relsonshipifeat patient Wanes Dae AMAIEZ 3475 West Alton Gloor Blvd. Suite A Brownsville Texas 78520 Ph: 956-541-6725 Fax: 956-541-2070