Medical Release Form

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Alliance Health Resources Mobile Division Ltd. | 2910 Center St
Deer Park, TX | 77536 | 281.479.6672

The following form is for office personnel and account setup purposes. It is not intended to be a means to contact Alliance Health Resources for emergency medical needs. If your matter is urgent, please call 911.

Release of Medical Information

Employee Name*
First Middle Last
DOB*
Month
Day
Year
SS#*
Company*
Employee ID
Address*
Street Address City State ZIP Code
County*
Phone*
Email*

Your Results may be sent to you by email. Please provide an email for which you can receive your results.
I hereby authorize ALLIANCE HEALTH RESOURCES Mobile Division, Ltd. to release all information obtained during medical surveillance and occupational related encounters to:
Employer*
Employer Address*
Street Address City State / Province / Region ZIP / Postal Code
Company Contact Person*
Company Contact Phone*
- This authorization shall expire one year after my employment ceases.
- I may revoke this authorization in writing by contacting your office at the above address.
- I understand that I may periodically be asked to update this Medical Release Form at the discretion of Alliance Health Resources Mobile Division, Ltd.
- I understand that my authorization provided means that the authorized organization can disclose, communicate or send my protected health information to the organization, entity or person identified above, including through the use of electronic means.
Signature*
Name
This field is for validation purposes and should be left unchanged.

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Release of Medical Information

Medical
Release Form