Medical Records Release Form

  • By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or a narrative of my protected health information, to the physician/person/facility/entity listed below.

  • The information you may release subject to this signed release form is as follows:

      • Complete Records
      • Lab Reports
      • Operative Reports
      • History & Physical
      • Radiology Reports
      • Hospital Records
      • Progress Notes
      • Pathology Reports
      • Medication Record
      • Care Plan
      • Treatment Record
      • Other (please specify below)
  • Release my protected health information to the following physician/person/facility/entity:

    Name: Dr. Travis Mendel Radiation Oncologist

    Address: 7420 Remcon Cir. Bldg. A

    City: El Paso State: TX Zip Code: 79912