TESTING HIPPA FORM

Authorization
I hereby authorize Guadalupe Regional Medical Center to release records of:*
- Employee
- Volunteer
- Student
- Physician
- Other
Employee Information*
First Name
Last Name
Phone
Email
Last 4 of SSN*
Date of Birth:*

MM slash DD slash YYYY
Record Release*
Release Employee Health Record to: (name of self/person/physician/company):*
The records requested are (TB test, immunization record, etc.):*
The records are requested for the following purposes: (personal, school, etc.):*
Delivery of Records*
How would you prefer Employee Health to provide records?*
- Pick of copy in Employee Health/Employee Services
- Email
- Fax
- Mail
Telephone number to call when records are ready*
Fax Number*
Email*
Name*

First

Last
Address*

Street Address

Address Line 2

City

State

ZIP Code
Permission to Release Information*
- By checking this box, I agree all information stated above is correct and I give permission to GRMC to release my Employee Health Information to the recipients stated above.
If you have any questions about the Employee Health Records Form, please call (830) 401-7325. Employee Health will provide this information within 3 – 10 days.

TESTING HIPPA FORM

    
Call us: 830.379.2411
1.800.506.6394
1215 E. Court Street 
Seguin, Texas 78155
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TESTING HIPPA FORM

Authorization

Employee Information*

Record Release*

Delivery of Records*