I hereby authorize the medical provider named above to release (by return mail, FAX, or other means of delivery) medical records, x-rays, and any other information in its possession pertaining to my:
TEXAS ORTHOPEDICS, SPORTS AND REHABILITATION ASSOCIATES
I also hereby authorize that a photocopy of this authorization be accepted with the same authority as the original. The information disclosed will be used for the purpose of continuity of care.
This authorization is subject to revocation by me at any time. In the absence of prior revocation by me, this authorization will automatically expire in one year.