Authorization Form For Release Of Patient Information

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Texas Tech University Health Sciences Center
Patient Name: _________________________________________
th
PO Box 5066, 3601 4
Street, 1B108
Lubbock, TX 79408-5066
TTUHSC MRN: ____________________________________
(806) 743-2608
1-888-300-9868
DOB/SSN: ____________________________________________
Authorization for Release of Patient Information
I request and authorize Texas Tech University Health Sciences Center to:
Release the following information to:
Name of Facility/Person: ________________________________________
Receive the following information from:
Address /City, State, Zip: ________________________________________
Release is for the Purpose of:
Information to be disclosed if requested:
Continued Care
Disability
One Year
X-ray results
by other health care provider
School
Two Years
Lab results
Insurance
Personal Review
Complete medical record
Schedule
Attorney
Billing statement
Immunization record
Other (please specify) _________________
Specific Specialty _______________________
Other (please specify) ____________________
I understand and agree that the information I am authorizing to be released may include:
(1) AIDS/HIV test results, diagnosis, treatment, and related information;
(2) Drug screen results and information about drug and alcohol use and treatment;
(3) Mental health information; and/ or
(4) Genetics testing;
Unless otherwise requested ____________________________________________________________.
I further understand that this Authorization is
I further understand that the person(s) I am
TO THE RECEIVING PARTY OF THIS
voluntary and I may refuse to sign this
authorizing to use or disclose my information
INFORMATION This information has been
Authorization. I further understand that my
may receive compensation (either directly or
disclosed to you for the sole purpose(s) stated
treatment will not be affected if I do not sign this
indirectly) for doing so.
in this Authorization. Any other use of this
form (45 C.F.R. 164.508 (c)(2)).
information without the express written consent
I further understand that I may refer to
of the patient is prohibited. These records may
I further understand that I may revoke this
TTUHSC’s Notice of Privacy Practices.
be protected by federal regulation (42 C.F.R.
Authorization at any time by notifying the Texas
Part 2).
Tech University Health Sciences Center (or the
RELEASE FROM LIABILITY I release and
agree to hold harmless TTUHSC Clinic (or
releasing facility) in writing, except to the extent
If the healthcare services (including examination
that action has been taken in reliance on it.
other releasing facility) and its agents,
and drug screening) are being provided at the
Unless earlier revoked, this Authorization
representatives, and employees from any
request of and being paid for by my employer
expires automatically 90 days from the day
and all liability associated with the release
(or prospective employer), I understand and
signed or 90 days after the last TTUHSC clinic
of confidential patient information in accord
agree that all records and information related to
visit or after all insurance or third party claims
with this Authorization. I understand
the healthcare services provided to me may be
have been paid or satisfactorily resolved,
TTUHSC Clinic (or the releasing facility)
given directly to my employer and if I wish to
whichever occurs last (45 C.F.R. 164.508
cannot be responsible for use or re-
obtain such information, I should contact my
(c)(2)).
disclosure of information to third parties (45
employer/prospective employee.
C.F.R. 164.508 (c)(2)).
I certify that this form has been fully explained to me, that I have read it or had it read to me*, and that I understand its contents.
_________________________
____________________________
_________________________________________
Date
Time
Patient/Other Legally Authorized Person
_________________________
____________________________
_________________________________________
Witness/Translator*
Print name
Print name and relationship to patient
TTUHSC Authorization for Release of Patient Information
Revised April 14, 2003
Approved by the HIPAA Forms Committee 04-02-2003

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