Authorization Form To Disclose Protected Health Information printable pdf download

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Developed for Texas Health & Safety Code § 181.154(d)

effective June 2013

Please read this entire form before signing and complete all the

NAME OF PATIENT OR INDIVIDUAL

sections that apply to your decisions relating to the disclosure

of protected health information. Covered entities as that term is

______________________________________________________________

defined by HIPAA and Texas Health & Safety Code § 181.001 must

Last

First

Middle

obtain a signed authorization from the individual or the individual’s

OTHER NAME(S) USED _________________________________________

legally authorized representative to electronically disclose that indi-

vidual’s protected health information. Authorization is not required for

DATE OF BIRTH Month __________Day __________ Year______________

disclosures related to treatment, payment, health care operations,

ADDRESS _____________________________________________________

performing certain insurance functions, or as may be otherwise au-

______________________________________________________________

thorized by law. Covered entities may use this form or any other

form that complies with HIPAA, the Texas Medical Privacy Act, and

CITY ____________________________STATE_______ ZIP______________

other applicable laws. Individuals cannot be denied treatment based

PHONE (_____)______________ ALT. PHONE (_____)_________________

on a failure to sign this authorization form, and a refusal to sign this

EMAIL ADDRESS (Optional): ______________________________________

form will not affect the payment, enrollment, or eligibility for benefits.

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH

REASON FOR DISCLOSURE

INFORMATION:

(Choose only one option below)

Person/Organization Name _____________________________________________________

Treatment/Continuing Medical Care

Address ____________________________________________________________________

Personal Use

City ______________________________________ State ________ Zip Code __________

Billing or Claims

Phone (_______)____________________Fax (_______)_____________________________

Insurance

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Legal Purposes

Disability Determination

Person/Organization Name _____________________________________________________

School

Address ____________________________________________________________________

Employment

City ______________________________________ State ________ Zip Code __________

Other ________________________

Phone (_______)____________________Fax (_______)_____________________________

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 box.

¨ All health information

¨ History/Physical Exam

¨ Past/Present Medications

¨ Lab Results

¨ Physician’s Orders

¨ Patient Allergies

¨ Operation Reports

¨ Consultation Reports

¨ Progress Notes

¨ Discharge Summary

¨ Diagnostic Test Reports

¨ EKG/Cardiology Reports

¨ Pathology Reports

¨ Billing Information

¨ Radiology Reports & Images

¨ Other________________

Your initials are required to release the following information:

______Mental Health Records (excluding psychotherapy notes)

______Genetic Information (including Genetic Test Results)

______Drug, Alcohol, or Substance Abuse Records

______ HIV/AIDS Test Results/Treatment

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 _________ Day __________ Year _________

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this au-

thorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that

prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I un-

derstand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that

is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provid-

ed by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursu-

ant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

SIGNATURE X__________________________________________________________________________

________________________

Signature of Individual or Individual’s Legally Authorized Representative

DATE

Printed Name of Legally Authorized Representative (if applicable): ____________________________________________________________________

If representative, specify relationship to the individual: ¨ Parent of minor

¨ Guardian

¨ Other ________________________________

A minor individual’s signature is required for the release of certain types of information, including for example, the release of information related to cer-

tain 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).

SIGNATURE X__________________________________________________________________________

________________________

Signature of Minor Individual

DATE

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