Form L-30a - Authorization Form To Release Confidential Information (Page 3 of 3) in pdf

Instructions for Obtaining Consent to Release Medical Information

Information contained in client records is confidential. With certain exceptions, the release of medical records is

prohibited by the provisions of the Medical Practice Act (Article 4495b, V.T.C.S.). In addition, social, financial,

educational and other types of information in client files may be protected by a constitutional or common law right to

privacy. There are civil and criminal penalties for the unauthorized release of such information.

The Medical Practice Act, the common law and the Constitution permit a health care provider to release these types

of information from an individual's record with the consent of the individual or a person authorized to consent for the

individual. For example, the Medical Practice Act states:

Occupations Code Sec. 159.005(a)(1-5) and (b). Consent for the release of confidential information

must be in writing and signed by the patient, or a parent or legal guardian if the patient is a minor, or a

legal guardian if the patient has been adjudicated incompetent to manage his personal affairs or an

attorney ad litem appointed for the patient, as authorized by the Texas Mental Health Code; the

Persons With Mental Retardation Act; Chapter XIII, Texas Probate Code, and Subtitle B Title 5,

Family Code; or a personal representative if the patient is deceased, provided that the written consent

specifies the following:

(A) the information or medical records to be covered by the release;

(B) the reasons or purposes for the release; and

Further, the Communicable Disease Prevention and Control Act (Chapter 81, Health and Safety Code) contains the

following specific requirements for the release of information relating to tests for AIDS, the human immunodeficiency

virus (HIV), and antibodies to HIV:

Sec. 81.103(d). An Authorization under this subsection must be in writing and signed by the person

tested or the person legally authorized to consent to the test on the person's behalf.

The

authorization must state the person or class of persons to whom the test results may be released or

disclosed.

The "Authorization to Release Confidential Information" form was developed to conform to these statutory

requirements. For this reason, when you are requested to release information from records under your control, the

form must be carefully completed to provide the information required by statute. If you are requested to provide

information from a client record to an institution (e.g., a hospital) rather than an individual, and you do not know the

name of the individual within the institution to whom the information is to be sent, insert the title of the responsible

person (e.g., the administrator, medical records librarian, etc.). Do not simply insert the name of the hospital.

The "Authorization to Release Confidential Information" form must be completed and signed by individual

clients when they request their personal health records be released.

The form may be used to obtain information from other providers and when used for that purpose, it should be

completed with the same concern for the statutory, common law and constitutional requirements. Such attention to

detail may ultimately save both time and effort.

The Medical Practices Act, the Communicable Disease Prevention and Control Act and certain other statutes, for

instance, those relating for mental health and mental retardation information, provide several other exceptions to the

rule of confidentiality relating to medical records.

ANY REQUEST FOR INFORMATION WHICH CANNOT BE ADDRESSED BY THE USE OF THE CONSENT TO

RELEASE CONFIDENTIAL INFORMATION FORM MUST BE REFERRED IMMEDIATELY TO THE OFFICE OF

GENERAL COUNSEL FOR NECESSARY ACTION. Because the Public Information Act and other statutes give a

very limited time period during which the agency must respond to requests for information, any delay in making these

referrals may lead to results which are adverse to the agency.

Please review the release form before releasing information. All blanks on the form must be filled in, the form must be

read by the client, and the form must be appropriately signed before the information is released. The client must

receive a signed copy of the authorization.

Texas Department of State Health Services

L-30a

(9/2004)

Form L-30a - Authorization Form To Release Confidential Information Page 3

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