Authorization For Use And Disclosure Protected Health Information Form printable pdf download

AUTHORIZATION FOR USE AND DISCLOSURE

PROTECTED HEALTH INFORMATION

Please read this entire form before signing and complete all

NAME OF PATIENT OR INDIVIDUAL

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

Last

First

Middle

the individual’s legally authorized representative to electronically

disclose that individual’s protected health information. Authorization

OTHER NAME(S) USED _________________________________________

is not required for disclosures related to treatment, payment, health

care operations, performing certain insurance functions, or as may

DATE OF BIRTH Month __________Day __________ Year______________

be otherwise authorized by law. Covered entities may use this

form or any other form that complies with HIPAA, the Texas

ADDRESS _____________________________________________________

Medical Privacy Act, and other applicable laws. Individuals

CITY ____________________________STATE_______ ZIP______________

cannot be denied treatment based on a failure to sign this

authorization form, and a refusal to sign this form will not affect the

PHONE (_____)______________ ALT. PHONE (_____)_________________

payment, enrollment, or eligibility for benefits.

EMAIL ADDRESS (Optional): ______________________________________

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH

REASON FOR DISCLOSURE

INFORMATION:

(Choose only one option below)

Person/Organization Name _____________________________________________________

Treatment/Continuing Medical Care

Personal Use

Address ____________________________________________________________________

Billing or Claims

City ______________________________________ State ________ Zip Code __________

Insurance

Phone (_______)____________________Fax (_______)_____________________________

Legal Purposes

Disability Determination

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

School

Person/Organization Name UT HEALTH NORTHEAST (Physician:

)

Employment

Address __11937 US Hwy 271 ___________________________________________________

Other

City ___ Tyler_______________________________ State __ TX_____ Zip Code __75708 __

STAT

877-5852

877-7758

Phone (__903__)____

__________

Fax (__903__)_

_____________

________________________

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.

Dates of Service:___________________________________________________________________________________

All health information

Past/present medications

Lab Results

History/Physical Exam

Physician’s orders

Patient Allergies

Operation Reports

Consultation Reports

Discharge Summary

Progress Notes

Diagnostic Test Reports

EKG/Cardiology Reports

Pathology Reports

Billing Information

Other:___________

Radiology Reports &

Images

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: Unless otherwise revoked, this authorization will expire 180 days from the date signed; or the following specific date (optional):

Month _________ Day __________ Year _________

RIGHT TO REVOKE: I understand that I may revoke this authorization at any time by notifying The University of Texas Health Science Center at Tyler aka UT

Health Northeast, Release of Information in writing at UTHSCT, ATTN: Release of Information, 11937 Hwy 271, Tyler, TX 75708 of my intent to revoke this

authorization. However, I also understand that such a revocation will not have any effect on any information already used or disclosed by UTHSCT before

UTHSCT received my written notice of revocation.

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): ____________________________________________________________________

 Parent of minor

 Guardian

 Other ________________________________

If representative, specify relationship to the 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)

SIGNATURE X__________________________________________________________________________ ________________________

Signature of Minor Individual

DATE

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Approved 09/2015