Thank You New Patient Registration Form Medical Records

To Seema Kazi, MD dba Mid Cities Psychiatry,

This is an authorization to release all Personal Healthcare Information to the listed Person(s) and/or Medical Entity/Entities below.

I hereby authorize the following listed Person(s) and/or Medical Entity/Entities to receive information pertaining to my medical care including my mental health information. I understand that all information can only be given after the listed parties present a picture ID in person. I understand that I have the right to revoke this authorization at any time by sending and/or giving a written notice to Mid Cities Psychiatry. This authorization is valid indefinitely until I revoke this authorization in writing.

I understand and agree that I have the right to revoke this authorization at any time by sending/giving a written notice to Mid Cities Psychiatry. And until I revoke this authorization in writing, this authorization is valid indefinitely.

This is an authorization of your medical information to be transferred between health care providers, health insurance companies and any other party involved in my medical care.

I hereby authorize the following facilities/hospitals and doctor(s) to release all Personal Healthcare Information to Seema Kazi, MD dba Mid Cities Psychiatry for treatment consultation and to better manage my health.

This request includes mental health progress notes, hospital summaries, echocardiogram reports, cardiac catheterization reports, laboratory reports, electrocardiograms, physician progress notes, labs, and any other healthcare information relating to my condition.

I have the right to revoke this authorization at any time by sending and/or giving a written notice to Mid Cities Psychiatry. This authorization is valid indefinitely until I revoke this authorization in writing.