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Get Tx Abcd Pediatrics Authorization To Release Or Disclose Protected Health Information 2021-2024

Bulverde Office 121 Bulverde Crossing, #100 Bulverde, TX 78163 P: 210-499-6400 F: 210-494-2631 New Braunfels Office 2115 Stephens Place, #900 New Braunfels, TX 78130 P: 830-214-6708 F: 830-358-7711 Boerne Office 124 E. Bandera Rd, #304 Borne, TX 78006 P: 830-816-5055 F: 830-816-5056 Authorization to Release or Disclose Protected Health Information Patient s Name: Date of Birth: / / Date of Request: Address:.

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