Protected Health Information Form Protected Health Info FormAlain E. Elbaz, MD, PLLC In the course of your medical care, we may release relevant medical information to your other physicians or health care providers, or as directed by court order. You have the right to request restrictions on how your medical information is used or disclosed. You may make changes to how your medical information is disclosed at any time by sending your new request in writing to our office or filling out the form again. Please fill out this form to indicate any additional people with whom we may share your medical information. If we do not have specific approval, we will only release your medical information to you and your other healthcare providers. Please Select which location (Cypress or Houston) 10726 Huffmeister Rd., Suite 120, Houston, TX 77065 4200 Twelve Oaks Drive, Houston, TX 77027 Date(Required) MM slash DD slash YYYY Patient Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Suffix Patient Date Of Birth(Required) MM slash DD slash YYYY Patient Email(Required) Patient Phone NumberPlease check how we may release your Protected Health Information to you (check all that apply) Direct contact only (phone or in person) Home phone voicemail Office phone voicemail Email Fax Mailed to Home Address Other Other0 of 250 max charactersAre there any additonal people that you wish to approve receiving your Protected Health Information? Yes No Additional Authorized Persons With Contact InfoPlease check how we may release your Protected Health Information to your Additional Authorized Person(s) (check all that apply) Direct contact only (phone or in person) Home phone voicemail Office phone voicemail Email Fax Mailed to Home Address Other Other0 of 250 max charactersSignature (please type your name)(Required)Reset to re-sign.PhoneThis field is for validation purposes and should be left unchanged.