Authorization Disclose Health Info LanguageEnglish (US) AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION Developed for Texas Health & Safety Code § 181.154(d) effective June 2013Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. Covered entities as that term as defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.NAME OF PATIENT OR INDIVIDUAL Last Name:* First Name:* Middle Name: Other Name(S) Used Address* Street AddressStreet Address Line 2CityPlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming StateZip Code Birth Date* JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Month12345678910111213141516171819202122232425262728293031 Day20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Email* Confirmation Emailexample@example.com Phone Number* -Area CodePhone Number Alt Phone Number -Area CodePhone NumberI AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION: Person/Organization Name* Person/Organization Name Person/Organization Address* Street AddressStreet Address Line 2CityPlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming StateZip Code Phone Number* -Area CodePhone Number Fax Number* -Area CodePhone Number Email* Confirmation Emailexample@example.comWHO CAN RECEIVE AND USE THE HEALTH INFORMATION? Person/Organization Name * Person/Organization Name Address * Street AddressStreet Address Line 2CityStateZip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRepublic of the CongoRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSouth SudanSpainSri LankaSudanSurinameSvalbardeSwatiniSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsIsle of ManUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Phone Number* -Area CodePhone Number Fax Number* -Area CodePhone Number Reason For Disclosure (Choose only one option)* Treatment/Continuing Medical CarePersonal UseBilling or ClaimsInsuranceLegal PurposesDisability DeterminationSchoolEmploymentOther What Information Can be disclosed? Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first bo* All health informationPhysician's OrdersProgress NotesPathology ReportsHistory/Physical ExamPatient AllergiesDischarge SummaryBilling InformationPast/Present MedicationsOperation ReportsDiagnostic TestRadiology Reports & ImagesLab ResultsConsultation ReportsEKG/Cardiology ReportsOtherYour initials are required to release the following information: Mental Health Records (excluding psychotherapy Initials Drug, Alcohol, or Substance Abuse Records Initials Genetic Information (including Genetic Test Results) Initials HIV/AIDS Test Results/Treatment Initials EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reach-ing the age of majority; or permission is withdrawn; or the following specific date (optional): /Month /DayYearDate Picker Icon Signature of Individual or Individual's Legally Authorized Representative* Clear DATE:* /Month /DayYearDateHour MinutesAMPM AM/PM Option A minor individual's signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, e.g., Tex. Fam. Code § 32.003 ***Name of Legally Authorized Representative (if applicable): If representative, specify relationship to the individual GuardianParent of minorOther SIGNATURE:* Clear DATE:* /Month /DayYearDateHour MinutesAMPM AM/PM Option Important Information About the Authorization to Disclose Protected Health Information Developed for Texas Health & Safety Code § 181.154(d) effective June 2013* Preview PDF Print FormSaveSubmitClear FormShould be Empty:
