Thank You New Patient Registration Form Medical Records

To Seema Kazi, MD dba Mid Cities Psychiatry,

I hereby authorize the release of my complete medical records to Seema Kazi, MD dba Mid Cities Psychiatry for the purposes of treatment, consultation, and care coordination.

This authorization includes, but is not limited to: hospital discharge summaries, echocardiograms, cardiac catheterization reports, laboratory results, electrocardiograms (EKGs), physician notes, mental health progress notes, and any other information relevant to my medical or psychiatric condition.
I understand that I may revoke this authorization at any time by submitting written notice to the Seema Kazi, MD dba Mid Cities Psychiatry. Unless revoked in writing, this authorization shall remain in effect indefinitely.

Please list all facility names, hospital names, and/or providers from whom records should be requested:

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.