Frood Eelani, DO

HIPPA

Frood Eelani, DO, Internal Medicine

Phone: 8179213626 Fax: 8179210391

By typing your name in the signature boxes you are consenting to digital signatures.

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 narrative of my protected health information to the person(s) listed below:

HIV/AIDS: I consent to the release of my positive or negative test results for AIDS or HIV infection, antibodies to AIDS, or infection with any other causative agent of AIDS with the rest of my medical records. PLEASE INITIAL * Date of Consent * Limitations on the information you may release subject to this release form are as follows: Records to be released:

Release my protected health information to FROOD EELANI, DO at 1315 Sixth Ave, Fort Worth, TX 76104 for the reason or purpose of continuing PCP care.

Patient Name * Date of Birth * Patient Signature (or parent/guardian if minor) * Date of Signature *

I understand that you will provide this information within 15 days from receipt of request and that a fee for preparing and furnishing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners