Bernard L. Rosenfeld, M.D., Ph.D.
Authorization to Release Health Information

___________________________________		___________________________________
Patient Name							Date of Birth
___________________________________		___________________________________
Telephone								Social Security
________________________________________________________________________  
Other Names Patient has Used

Send Records to: Bernard L. Rosenfeld, M.D., Ph.D.
		     7400 Fannin St., Suite 910
		     Houston, Texas 77054-1921
		     (713)790-0099	
			        
I [ ] do [ ] do not (check applicable box) authorize this information to be faxed. 
If yes, fax number: (713) 790-0527

This information is being disclosed for the purpose of Continuing Health Care.

For Healthcare Covering the Period(s) [ ] All or From: ____________ To: ____________

Complete Health Record to be disclosed or (check appropriate boxes):	                      
[X] Operative Report & Pathology Report for Tubal Ligation Surgery from year _____
[ ] History & Physical Exam     [ ] Progress Notes      [ ] Discharge Summary       
[ ] X-Rays / Ultrasounds           [ ] Laboratory Tests   [ ] Consultations         
  
I understand that specific information to be released may include AIDS or HIV, Alcohol and/or Drug Abuse, and Mental Health.	

I understand that if I request copies of records for myself or a member of my family, a review of this information with my physician or other healthcare provider is encouraged. I understand that if the physician does not feel it is in my best interest, I may designate another healthcare provider to receive these records. I accept responsibility for these copies and information contained herein.

Unless otherwise indicated, this authorization will expire ninety (90) days from the date of signature. The physician and employees are released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. I understand that this authorization may be evoked in writing at any time, except to the extent that action has been taken in reliance on this authorization for the purposes stated above.

I understand that there may a fee for preparing and furnishing thus information.

____________________________________________   	________________________	__________
Signature of Patient or Legal Representative	Relationship to Patient		Date