Authorization To Release Medical Information From Usmd Physician Services
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1AUTHORIZATION TO RELEASE MEDICAL INFORMATION
FROM
USMD PHYSICIAN SERVICES
I, ___________________________________________________________________________________________, hereby authorize
(Name of patient or legal representative)
q
q
q
USMD Physician Services to disclose the following information by
mail
fax
orally to:
Name: ________________________________________________________________________________________________________
(Name of person/entity who should receive records)
Address: ______________________________________________________________________________________________________
(Address of person/entity who should receive records)
City, State, Zip Code: __________________________________________________________________________________________
Phone Number: __________________________________________ Fax Number: _______________________________________
From the health records of: ____________________________________________________________________________________
(Name of person whose record will be disclosed)
Name of Patient: _________________________________________________________________ D.O.B.____________ Age:_____
LAST
FIRST
M.I.
For the purpose of:_____________________________________________________________________________________________
My authorization extends only to those data elements/documents marked below:
All Health Information
Progress Notes
Statements of Charges or Payments
Substance Abuse Records
_______
Initials
AIDS or HIV Information
_______
Genetic Information (inc. genetic test results)
______
Initials
Initials
History and Physical Examination
Discharge Summary
Copies of Records of Reports Provided to the
Consultation Reports
Above Named (i.e. Hospital, Lab, Clinic, etc.)
Hepatitis Information
Mental Health and/or Alcohol & Drug Abuse
Photographs, Videotapes, Digital, or Other Images
Treatment
_______
Initials
Record of visit for a specific date(s). Specific dates include or are limited to:
_________________________________________________________________________________________________________________
Other (must be specific):
_______________________________________________________________________________________________________________
This authorization is given freely with the understanding that:
1.
Any and all records, whether written, oral, or in electronic format, are confidential and cannot be disclosed without my prior
written authorization, except as otherwise provided by law.
2.
A photocopy or fax of this authorization is as valid as this original.
3.
I may revoke this authorization at any time in writing, except where information has already been released.
4.
USMD Physician Services, its employees, officers, and physicians are hereby released from any legal responsibility or liability for
receipt of the above information to the extent indicated and authorized herein.
5.
Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and may no
longer be protected by federal and state privacy laws.
6.
Treatment, payment, enrollment, or eligibility of benefits may not be conditioned on obtaining this authorization.
______________________________________
_____________________________________________________________
Patient/Legal Representative Signature
Date
_____________________________________________________________
______________________________________
Relationship to Patient
Expiration Date of Authorization
unless otherwise noted, authorization expires 1 year from date of signature above
_____________________________________________________________
______________________________________
Witness Signature
Date
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 of Minor Individual
Date
A.06.form.Authorization.Release.FROM.USMD.Rev110915
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