Authorization To Release And Disclose Patient Information Form
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1Student Health Services
3601 4
th
St. MS 7208
Lubbock, TX 79430
806-743-2860
806-743-2122(fax)
Authorization To Release and Disclose Patient Information
PATIENT INFORMATION
PATIENT NAME: ________________________________ DATE OF BIRTH:_____________
TTUHSC MRN:___________
Address:_______________________________ Day Phone:________________
City:_____________________________ State:________ Zip:_______________
RECEIVING PARTY
NAME:__________________________________________
Send the information to:
Address:______________________________ Phone:________________
Receive the information
City:___________________________ State:__________ Zip:__________
from:
INFORMATION TO BE
Any and All records (complete record)
RELEASED
Only records types checked below:
Progress notes/clinic notes
Schedule
(What do you want sent or
Laboratory reports
Other (please specify)_____________________
released? Check the
Immunization record
Billing Records (dates) ___________________
appropriate box.)
Medication record
Routine Record Set (indicate date(s) of service_________)
Schedule
(office visit, lab, radiology, medicines, immunizations)
I agree that the following information may be released/used only as indicated below:
1.
AIDS/HIV test results, diagnosis, treatment, and related information
Yes___ No___
2.
Drug screen results and information about drug and alcohol use and treatment
Yes___ No___
3.
Mental health information
Yes___ No___
4.
Genetic testing
Yes___ No___
RELEASE INSTRUCTIONS
(How do you want the
Paper
Electronic Form (CD/USB)
information?)
PURPOSE OF RELEASE
Continuing Care by other health care provider
Disability
School
(Why is it needed?)
Insurance
Personal review
Attorney/Legal
Other_____________________________
To The Receiving Party Of
This information has been disclosed to you for the sole purpose(s) stated in this Authorization. Any
This Information
other use of this information without the express written consent of the patient is prohibited. These
records may be protected by federal regulation. Federal rules prohibit you from further disclosure
unless you have received written consent from the person to whom it pertains or as otherwise
permitted by 42 CFR Part 2.
This authorization is voluntary and I may refuse to sign it. My treatment or payment for services will not be affected if I do not
•
sign this Authorization.
This Authorization may be canceled by submitting a written notice to Texas Tech University Health Sciences Center (or the
•
releasing facility). Information may be released until my written notice of cancellation is received.
This Authorization expires 180 days from the date signed or on the following date or event (specify) ___________
•
Additional information is in TTUHSC’s Notice of Privacy Practice.
•
•
If the healthcare services are being provided at the request of and being paid for by my employer (or prospective employer), I
understand and agree that all records and information related to the healthcare services provided to me may be given directly to
my employer and if I wish to obtain such information, I must contact my employer/prospective employer.
RELEASE FROM LIABILITY: I release and agree to hold harmless TTUHSC Clinic (or other releasing facility) and its agents,
representatives, employees from any and all liability associated with the release of confidential patient information in accord with the
Authorization. I understand TTUHSC Clinic (or the releasing facility) cannot be responsible for use or rediscover of information to third
parties.
I certify that this form has been fully explained to me, I have read it or had it read to me*, and I understand its contents.
Date
Print Your Name
Patient or Legally Authorized Signature
R
Time
Witness/Translator *
elationship to patient
TTUHSC Authorization for Release of Patient Information
Revised February 2013
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Parent category: Legal