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Get Tx 73115 2015

Name Of Protected Health Information Date of Birth Address Medical Records# Telephone # ( ) I hereby authorize Memorial Hermann Health System to release my records from the following facilities (please check ONLY facilities that apply): HOSPITALS o Memorial City o NW/Greater Heights o Southwest o Northeast o Sugar Land 921 Gessner Rd o Hermann-TMC 6411 Fannin o OSH 1635 N. Loop West 7600 Beechnut o Katy 23900 Katy Fwy 5410 West Loop South OUTPATIENT CENTERS: o River Oaks 18951 Mem.

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