Authorization To Disclose Protected Health Information

Patient Information

Patient Name
(If none, enter N/A)
Patient Date of Birth
Patient Address
Email

I AUTHORIZE THE FOLLOWING TO  DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION:

Address

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)

Type of information to release:
(If all health information is to be released, then check only the first box.)

YOUR INITIALS ARE REQUIRED TO RELEASE THE FOLLOWING INFORMATION:

(excluding psychotherapy notes)
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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earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn;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):
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.

Electronic Signature Disclosure and Consent:

Agree
By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature(s) is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature(s) on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor.
Signature of Individual or Individual's Legally Authorized Representative :
Date Signed:
Printed Name of Legally Authorized Representative (if applicable):
Signature of Minor Individual:
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).
Date Signed:
(Date signed by minor)