669 Airport fwy. #401, Hurst, TX 76053

Consent for Disclosure of Medical Information

  • AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

  • to use or disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.

    Recipient: I authorize my health care information to be released to the following recipient(s):

    Name: KISHORE SUNKARA, M.D.

    Address: 669 Airport Freeway, #401, Hurst, TX 76053

    Purpose: I authorize the release of my health information for the following specific purpose:
    For Evaluation& Treatment

    <(Note: “at the request of the patient” is enough if the patient is initiating this Authorization)

    Information to be disclosed: I authorize the release of the following health information: (check the applicable box below)

  • Term: I understand that this Authorization will remain in effect:
  • Until the Provider fulfills this request.
  • Redisclosure: I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

    Refusal to sign/right to revoke I understand that I can revoke this authorization by providing a written notice of revocation to the office of Kishor Sunkara, M.D. at the above address. The revocation will be effective immediately upon my health care provider’s receipt of my written notice,

  • Date Format: MM slash DD slash YYYY
  • If Individual is unable to sign this Authorization, please complete the information below:
  • Date Format: MM slash DD slash YYYY
  • NOTE: This Authorization does not extend to HIV test results, outpatient psychotherapy notes, drug or alcohol treatment records that are protected by federal law, or mental health records that are protected by the Lanterman-Petris-Short Act.