Authorization Disclose Health Info

Please 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.

Last Name:*

First Name:*

Middle Name:

Other Name(S) Used

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Birth Date*

MonthDayYear

Email*

Confirmation Emailexample@example.com

Phone Number*

Area CodePhone Number

Alt Phone Number

Area CodePhone Number

Person/Organization Name*

Person/Organization Name

Person/Organization Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

Fax Number*

Area CodePhone Number

Email*

Confirmation Emailexample@example.com

Person/Organization Name *

Person/Organization Name

Address *

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone Number*

Area CodePhone Number

Fax Number*

Area CodePhone Number

Reason For Disclosure (Choose only one option)*

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*

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of the occurrence of the death of the individual; the individual reach-ing the age of majority; or permission is withdrawn; or the following specific date (optional):

MonthDayYear

Signature of Individual or Individual's Legally Authorized Representative*

Clear

DATE:*

Date

Hour MinutesAM/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:*

Date

Hour MinutesAM/PM Option

Important Information About the Authorization to Disclose Protected Health Information Developed for Texas Health & Safety Code § 181.154(d) effective June 2013*

Existing Patients

New Patients

Authorization Disclose Health Info

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION Developed for Texas Health & Safety Code § 181.154(d)

NAME OF PATIENT OR INDIVIDUAL

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION:

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Your initials are required to release the following information:

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