CIPM AUTHORIZATION TO RELEASE MEDICAL RECORDS

I hereby authorize the release of my medical records as follows:

FROM: Consultants in Pain Medicine, PLLC

Address: 45 NE Loop 410, Ste. 850, San Antonio, TX 78216

Phone: 210-805-9800

Fax: 210-805-8770

Authorization & Acknowledgment:

I understand that:

• This authorization is voluntary and may be revoked at any time by submitting a written request to the releasing party, except to the extent that action has already been taken based on this authorization.
• Once information is released, it may no longer be protected by HIPAA.
• I may be responsible for any applicable fees allowed under Texas law for the processing and copying of medical records, postage and other delivery expenses.
• This authorization will expire two years from the date signed unless otherwise specified below:

• If signed by a personal representative (e.g., legal guardian, medical POA), complete: