Authorization for Release of Information 203 Walls Drive, Suite 100, Cleburne, TX 76033 Phone: 817-760-0234 ∙ Fax: 817-641-3355

Patient Name:_________________________________

Date of Birth: _________________

I hereby request and authorize Cleburne Digestive Health, PLLC to obtain al of my medical records and information for all service dates from:

Name of Provider/Facility ________________________________________________________

Address_______________________________________________________________________

Telephone_____________________________

_________________________________________ Signature of patient or patient’s representative

Fax___________________________

________________________ Date