Karina Harris
 
 
 2022/09/10 12:27 FROM- CWFMD 
 936-703-5455 
 T-236 P0003/0048 F-222 
 HIPAA AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION 
 (Medical Records) 
 Medical Provider Name: Conroe Willis Family Medicine 
 Patient Name: Karina Harris 
 Date of Birth: 
 1987/04/07 
 Address: 
 9851 FM 1097 Rd. West. Suite 120. Willis, TX 77318 
 Dates of care: 
 2022/27/01 to present 
 I authorize and direct Covered Entity/Medical Provider to disclose and to supply copies of my protected 
 health information (medical records) described below to any member of Levin, Papantonio, et al. 316 
 S. Baylen St., Suite 600, Pensacola, Florida 32502. and/or their agents, for the purpose of litigation. 
 Information to be disclosed: 
 X 
 Copy of the complete medical record 
 Surgical Report 
 Discharge Summary 
 Radiology Report 
 Face Sheet 
 Physical Therapy Notes 
 History & Physical Report 
 Laboratory Reports 
 Other (specify) 
 Expiration 
 This authorization will expire two years from the date of patientine signature. 
 I 
 acknowledge, and hereby consent to such, that the released information may contain alcohol, drug 
 abuse, psychiatric, HIV testing. HIV results or AIDS information 
 (Initial) 
 DATE 2017/26/11 
 Signature of Patient of Representative 
 Authority of Patient (parent of minor, 
 guardian, etc); Copies of documentation such as a 
 Healthcare Power of Attorney may be attached. 
 Karina Harris 
 Print Name of Patient or Authority of Patient
