Patient Authorization For Release Of Health Records To External Parties

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Patient Authorization for Release of Health Records to External Parties
1. I authorize _________________________________________________________________________________ to disclose
information from the health records of: ___________________________________________________________________
(patient)
Account #: __________________________________ Date of Birth: __________________________________________
2. The information is to be disclosed to: ___________________________________________________________________
Address (sender/receiver if other than UT Health Science Center): ______________________________________________
City, State, Zip: ______________________________________________________________________________________
Contact Person: ______________________________________________________________________________________
Phone/Fax: _________________________________________________________________________________________
I authorize this information to be disclosed in the following ways:
Written/Photocopy/Paper
Electronic Format
Verbal
Fax
Electronic Mail *
Purpose of the disclosure: ____________________________________________________________________________
3. Dates of Treatment:
From: _______________________________ To: _________________________________
Specific reports to be disclosed:
Progress Notes
Laboratory Reports
Operative Reports
Discharge Summary
Radiology Reports
Consultation Reports
X-ray films or other images
Photographs/Videotapes
Records from other facilities
Entire Health Records (including, but not limited to, information regarding medical/health treatment, insurance,
demographics, referral documents, and records from other facilities.)
Other (Specify):__________________________________________________________________________________
I give specific authorization to disclose the following information:
HIV test results
Documentation of AIDS diagnosis
Drug and alcohol abuse treatment records
Psychiatric/Mental Health treatment records
I understand that I may withdraw or revoke my permission at any time. If I withdraw my permission, my information may no
longer be used or released for the reasons covered by this authorization. However, any disclosures already made with my
permission are unable to be taken back. I may revoke this authorization by notifying UT Health Science Center in writing.
My treatment will not be based on the completion of this authorization form. The information to be released by this
authorization may be re-released by the person or organization that receives it and may no longer be protected by Federal or
Texas privacy regulations.
Unless revoked earlier, this authorization expires in one year unless I specify another time: __________________________
I release the individual or organization named in this authorization from legal responsibility or liability for the disclosure of
the records as authorized on this form. I understand that this authorization is voluntary and that I may refuse to sign it. I will
be provided a copy of this signed authorization, if requested. A photocopy of this authorization is as valid as the original.
_______________________________________________
_____________________________________________
Signature of Patient (or Patient Representative)
Date
_______________________________________________
_____________________________________________
Printed Name of Patient or Patient Representative
Authority of Representative to Act for Patient
(Relationship to Patient)
* Need to ensure separate E-mail Authorization Agreement is signed.
Note: Release of Psychotherapy notes requires a separate authorization.
10/2012

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