Authorization For Release Of Patient Information Form

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AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
Name of Patient: __________________________________________________________ Phone Number: ___________________________
Other Names Used: _________________________ Date of Birth: _________________Social Security Number: XXX --______ - ________
I, the undersigned, authorize the release of or request access to the information specified below from the medical record (s) of the above-named
patient.
PATIENT INFORMATION IS NEEDED FOR: PLEASE SELECT ONE OPTION
Continuing Medical Care
Military
Personal Use
School
Insurance
Legal Purposes
Social Security/Disability
Other: _________________________________________________
DATE (s) OF TREATMENT: __________________________________________________________________________________________
INFORMATION TO BE RELEASED OR ACCESSED:
History & Physical
Consultation Report
Emergency Room Record
Operative Reports
Discharge/Death Summary
Face Sheet
Lab/Pathology Reports
Radiology Reports
Discharge Instructions
Behavioral Health
Radiology Images
Other _________________________________________________
FORMAT REQUESTED FOR INFORMATION TO BE PROVIDED:
Paper
Electronic media* (requires 2 business days)
Release to MyCare account* (*only applies to data stored electronically)
METHOD OF DELIVERY:
Pick Up (You will be notified via a telephone call when records are ready for pick up)
Mail to Address listed below
__________________________________________________________________________May release the above information to:
(Hospital Name)
__________________________________________________________________________________________________________________
(Name)
__________________________________________________________________________________________________________________
Address (Street, State, Zip Code)
Phone Number
I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.
Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected. I
understand that the specified information to be released may include, but is not limited to: history, diagnoses, and/or treatment of drug or alcohol
abuse, mental illness, or communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome
(AIDS).
I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for
participation in research programs, or authorization of the release of testing results for pre-employment purposes. I understand that I may
revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. I understand I
may be charged a retrieval/processing fee and for copies of my medical records according to Texas Hospital Licensing law.
This authorization will expire One Hundred Eighty (180) days from the date of my signature unless I revoke the authorization prior to that time or
unless otherwise specified by date, event, or condition as
follows:
_____________________________________________________________.
Date: _____________________
Signature: ________________________________________________________________
Patient or Legally Authorized Representative
________________________________________________________________
Printed Name of Patient or Legally Authorized Representative
__________________________
________________________________________________________________
For Department use: MRN/Acct #
Relationship to Patient
_________________________________________________________________________________________________________________
AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
Form NO. 998540768 (Rev. 01/16) PAGE 1 of 1
PATIENT IDENTIFICATION
Texas Health __________________________
*9810*
*9810*

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