Nauman Qureshi, MD Fax: (337) 721-9902

Phone: (337) 721-9992 Nauman Qureshi, MD Fax: (337) 721-9902 Board Certified – Internal Medicine 333 South Ryan St. #250 Lake Charles LA 70601

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI)

PATIENT NAME: ______DATE OF BIRTH: ______INFORMATION TO BE RELEASED FROM: Name/Agency: ______Address: ______Phone: ______Fax:______

INFORMATION TO BE RELEASED TO: Name/Agency: Dr. Nauman Qureshi / Comprehensive Medical Clinic Address: 333 Dr. Michael Debakey Drive, Suite #250 Lake Charles, LA 70601______Phone: 337-721-9992 Fax: 337-721-9902

REASON FOR RELEASE: New patient to our practice / Mutual patient

INFORMATION TO BE RELEASED:  All information  HIV / STD  Consultation Reports  Diagnoses (Medical)  Lab Reports  X-Ray Reports  Physician’s Orders  Progress Notes  Discharge Summary  Treatment Plans  Drug/Alcohol  Diagnoses (Psychiatric)  Psychiatric Evaluation  Physicals  Psychological Test  Immunization Records  Other (Specify):

1 Phone: (337) 721-9992 Nauman Qureshi, MD Fax: (337) 721-9902 Board Certified – Internal Medicine 333 South Ryan St. #250 Lake Charles LA 70601 Patient’s Initial: _ _

This authorization is effective immediately and is subject to revocation, in writing, at any time, except to the extent that action has already been taken. Otherwise, this authorization expires on ______. I am aware of and have been advised of the provisions of existing Federal (Health Insurance Portability and Accountability Act (HIPPA) and State Statutes, Rules and Regulations, which provided for my right to confidentiality of the information in these records.

I realize that this is a required authorization and that I must voluntarily and knowingly sign this authorization before any records can be releases, and that I may refuse to sign, but in that event, the records cannot and will not be released.

I further release my attending physician, the clinic/hospital and employees of the clinic/hospital, school and employee from any liability arising from the release of information to the person(s)/agency designated above. A PHOTO COPY/FAX OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL.

I understand that information used are disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPPA regulations. * Please allow up to two weeks for the forms to be processed and completed. There may also be a fee charge. * ______has the right to receive a true copy of this authorization (NAME OF PATIENT/GUARDIAN) Placing initials ______to the left of this clause on the original authorization. (HIS OR HER)

***______SIGNATURE OF PATIENT DATE

______

2 Phone: (337) 721-9992 Nauman Qureshi, MD Fax: (337) 721-9902 Board Certified – Internal Medicine 333 South Ryan St. #250 Lake Charles LA 70601 SIGNATURE OF PARENT/GUARDIAN/REP (When Applicable) DATE RELATIONSHIP TO PATIENT: ______