There is a $25.00 fee for records obtained from our office. We are able to take this payment online through PayPal. This can be paid with Visa, MasterCard, or a personal PayPal account. Please complete the form below for release purposes, and then you will be directed to a PayPal page to complete your payment transaction.
Records will not be compiled unless this payment is completed.
I HEREBY AUTHORIZE ENT CENTERS OF N TEXAS AND ITS AGENTS AND EMPLOYEES TO RELEASE INFORMATION AND COPIES OF RECORDS PERTAINING TO MY MEDICAL CARE AND TREATMENT, WHICH COULD INVOLVE INFORMATION ABOUT COMMUNICABLE OR VENERAL DISEASE, MENTAL HEALTH, OR DRUG SUBSTANCE OR ALCOHOL ABUSE.
WARNING: We have no control over any information and records released to any person, firm, or agency under this authorization and it is therefore possible that a release of this information or records may occur by such party.
RELEASE: I release ENT Centers of N Texas and its employees and agents from any liability in connection with the use or disclosure of the information and records released to any party pursuant to this authorization. Red Star * is a Required Field