Authorization To Disclose Protected Health Information

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 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 obtain a signed authorization from the individual or the individual's legally authorized representative to electronically disclose that individual's protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits. NAME OF PATIENT OR INDIVIDUAL ______________________________________________________________ Last First Middle OTHER NAME(S) USED _________________________________________ DATE OF BIRTH Month __________Day __________ Year______________ ADDRESS _____________________________________________________ ______________________________________________________________ CITY ____________________________STATE_______ ZIP______________ PHONE (_____)______________ ALT. PHONE (_____)_________________ EMAIL ADDRESS (Optional): ______________________________________ REASON FOR DISCLOSURE (Choose only one option below) ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ Treatment/Continuing Medical Care Personal Use Billing or Claims Insurance Legal Purposes Disability Determination School Employment Other ________________________ I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION: Person/Organization Name _____________________________________________________ Address ____________________________________________________________________ City ______________________________________ State ________ Zip Code __________ Phone (_______)____________________Fax (_______)_____________________________ WHO CAN RECEIVE AND USE THE HEALTH INFORMATION? Person/Organization Name _____________________________________________________ Address ____________________________________________________________________ City ______________________________________ State ________ Zip Code __________ 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 Physician's Orders Progress Notes Pathology Reports ¨ ¨ ¨ ¨ History/Physical Exam Patient Allergies Discharge Summary Billing Information ¨ ¨ ¨ ¨ Past/Present Medications Operation Reports Diagnostic Test Reports Radiology Reports & Images ¨ ¨ ¨ ¨ Lab Results Consultation Reports EKG/Cardiology Reports Other________________ Your initials are required to release the following information: ______Mental Health Records (excluding psychotherapy notes) ______Drug, Alcohol, or Substance Abuse Records ______Genetic Information (including Genetic Test Results) ______ 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 reaching 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 authorization 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 understand 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 provided by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursuant 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 certain 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 Page 1 of 2 ________________________ DATE American LegalNet, Inc. www.FormsWorkFlow.com IMPORTANT INFORMATION AbOUT THE AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION Developed for Texas Health & Safety Code § 181.154(d) effective June 2013 The Attorney General of Texas has adopted a standard Authorization to Disclose Protected Health Information in accordance with Texas Health & Safety Code § 181.154(d). This form is intended for use in complying with the requirements of the Health Insurance Portability and Accountability Act and Privacy Standards (HIPAA) and the Texas Medical Privacy Act (Texas Health & Safety Code, Chapter 181). Covered Entities may use this form or any other form that complies with HIPAA, the Texas Medical Pri