Authorization For Use, Request And Disclosure Of Protected Health Information


Medical Record Number:
Patient Name:
Social Security No.:
Date of Birth:
Phone No.:
Zip Code:
I, __________________________________, authorize Harris Health System or ______________________________, to disclose and
provide copies of the health-care information indicated below from my medical record to the following entity, person, or class of persons:
Name of person(s) or company to receive information
Phone Number
Street Address
Zip Code
Information To Be Released – Covering the Periods of Health Care
From (date) ______________________________________________ to (date) __________________________________________________
Please check type of information to be released:
 Admission Sheet
 History and Physical
 Discharge Summary
 Other Healthcare Records
 Autopsy
 Operative Report
 Pathology Report
(created by another provider)
 Footprints
 Laboratory Report
 Radiology Report (X-Ray, MRI, Ultrasound, etc)  Clinic Visit
 Entire Record
 Entire Record Excluding Nurses Notes
 Emergency Room Sheet
 Other (specify)
 Itemized Bill
 Lab / Slides
 Radiology Images (MRI, chest X-Ray, etc.)
 Psychotherapy Notes (If this box is checked,
 Complete Billing Record
 Block / Specimens
no other box may be checked)
Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release
I understand and agree that the information requested may contain reference(s) to drug and/or alcohol abuse, psychiatric care, sexually transmitted disease,
HIV/AIDS, Hepatitis B or C testing, and/or other sensitive information.
 Paper  Compact Disc (CD)
Purpose of Request/Disclosure
 Treatment or Consultation
 At the request of the Patient
 Billing or claims payment
 Requested for Government Benefit
 To enable the donation and use of my tissue for research through the tissue repository as described in protocol No.:
 Other, (specify) _____________________________________________________________________________________________________________
I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the
Health Insurance Portability and Accountability Act of 1996. This facility, its employees, officers and physicians are hereby released from any
legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
This authorization will automatically expire in 180 days from the date of signature unless (1) an expiration event or date is provided; or (2) "none"
has been entered (only if the purpose of this authorization is research).
Expiration Date or Event (eg. discharge from hospital or delivery of requested information)
I understand that this authorization may be revoked by me or my personal representative by written and dated notice to Harris Health System, except to the extent
that disclosure of information has been made prior to receipt of the revocation by Harris Health System.
Signature of Patient or Personal Representative Who May Request Disclosure
I understand that I do not have to sign this authorization, and my treatment or payment for services will not be denied if I do not sign this form
unless specified above under Purpose of Request. I can inspect or obtain a copy of the protected health information to be used or disclosed.
Signature of Patient Date
Authority to Sign if not patient ________________________________________
Witness Signature
 Photo ID
 Matching Signature
 Other, specify ___________________________________
Identity of Requestor Verified via:
Distribution: Original - Medical
Record Copy - Patient
Retention: HR-4800-04
280342 (04/14) Front


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Parent category: Legal