Release of Confidential Information Consent

RELEASE OF CONFIDENTIAL INFORMATION CONSENT BAYLOR METHODIST PRIMARY CARE ASSOCIATES

______Patient Name (Please print) (First, Middle, Last)

______Address City State Zip

______Date of Birth Social Security Number Phone Number (FROM) I hereby freely, voluntarily, and without coercion, authorize

Baylor-Methodist Primary Care Associates 6500 Fannin, Suite 1003 Houston, Texas 77030

(TO) to release a copy of my medical information to:

Kevin Scott Winfield, M.D., P.A. 2060 Space Park Drive, Suite 304 Nasssau Bay, Texas 77058 Fax: (281) 335-7598 Reason records are being requested: (Please check one) __ Insurance Claim __ Review by Attorney __ Disability _X_ Continuing Care _X_ Care by Physician __ Other (Please specify)______Date of next appointment: ______

MY MEDICAL RECORDS MAY INCLUDE INFORMATION REGARDING TESTING OR DIAGNOSIS AND/OR TREATMENT OF CHEMICAL DEPENDENCY, HIV TESTING, AND/OR HIV TREATMENT OR TREATMENT FOR ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS), PSYCHIATRIC DISORDERS AND/OR DRUG/ALCHOL ABUSE. THE INFORMATION TO BE RELEASED INCLUDES:

DATE (S) OF THE RECORDS NEEDED: ___Sept 01, 1998 – May 31. 2002______CHECK ALL THAT APPLY: ___ PERTINENT INFORMATION FOR CONTINUING CARE, OR _X_ Discharge note _X_ Pathology Report __Eye Records _X_ X-ray Report _X_ Shot Records _X_ History & Physical _X_Lab Results _X_ Daily Progress Notes _X_Consultation reports _X_ Other (Explain)______

This consent will expire 180 days from the date signed below. I understand that I may revoke this consent at any time. It must be revoked in writing, addressed and sent to Superior Records Management. ______Patient (or LEGAL GUARDIAN) Signature Date ______Witness Signature Date

Please see reverse side for instructions for obtaining records

Instructions for Obtaining Records Baylor Methodist Primary Care Associates has contracted with Superior Records Management to safely store and accurately provide copies of your records. Please follow these instructions to properly complete the required information and fees to allow Superior Records Management to provide your records.

If you are the patient requesting your record to be sent to your new physician, or a physician requesting the records, you will need to answer the following questions:

Name of New Physician:______Kevin Scott Winfield, M.D.______

Name of Institution/Practice:______Kevin Scott Winfield, M.D., P.A.______

Physician Address:______2060 Space Park Dr., Suite 304______

City, State, Zip:______Nassau Bay, Texas 77058______

The phone number of your new physician:__(281) 335-7588______(281) 335-7598 (fax)______

There are three choices of how your new physician may receive your records. The first choice is to have Superior send your records electronically via their safe and secure website. There is no charge for this method. This is absolutely safe and totally confidential. With this method your physician would receive a letter from Superior Records Management within ten (10) days of receipt of your request, which would include the instructions and allow your physician to view, print, and save your records.

With the other methods the only costs that will apply are for the choice of delivery of a physical hard copy.

_____ Provide physician with record electronically ______0______

_____ Via US Priority Mail. Shipping and handling fee is $10.00. ______

_____ Via Overnight Service-Shipping and handling fee is $15.00 ______

Check the appropriate method of delivery, and include a check made out to Superior Records Management for the appropriate amount and mail to:

Superior Records Management 997 Beauchamp St. Greenville, MS 38703

Questions regarding your request can be directed to Superior Records Management via one of the following ways: Phone: 866-332-5404 or 662-332-5404 Fax: 662-332-5519 Website: www.superior-rm.com Email: [email protected]