Authorization To Use & Disclose Health Information Form

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Park Plaza/Plaza Specialty Hospital
AUTHORIZATION TO USE & DISCLOSE
1313 Hermann Drive
Houston, TX 77004
HEALTH INFORMATION
713-527-5007
Fax: 713-522-3990
I authorize
__________ Park Plaza Hospital
__________ Plaza Specialty Hospital
and the Physicians who treated ________________________________________________________contact #_______________________
Full legal name of Patient
_________________________________________________
____________________________________________________
Patient’s date of birth
Social Security Number
To release to: ____________________________________________________________________________________________________
Specific name of Hospital, Physician, Service Agency or Third Party
Street
City
State
Zip Code
For the purpose of ________________________________________
_____________________________________________
State specific reason
Dates/Types of Service
The following specific information from my Medical Record:
__________ Discharge Summary
__________ X-Ray Reports
__________ X-Ray Films
__________ History & Physical
__________ Alcohol and/or drug abuse information (See 1 below)
__________ Operative Report
__________ HIV-related information (See 2 below)
__________ ER Records
__________ Psychiatric related information
__________ Lab Reports
__________ Other: Specific: ___________________________________
1. Confidentiality of DRUG/ALCOHOL ABUSE records are protected by Federal Regulations (42C.F.R., Part 2)
2. Confidential HIV-RELATED INFORMATION is any information that is likely to identify, directly or indirectly, someone as having been
tested for or actually having HIV infection. Antibodies to HIV, AIDS, or related infections or illness, or someone suspected of having HIV as a
result of high risk activities. PATIENT DOES NOT HAVE TO AUTHORIZE RELEASE OF HIV-RELATED INFORMATION.
I DO NOT authorize release of HIV-related information ________________________________________________________________
Name
Date
I understand that I may revoke this consent at any time by providing written notice of revocation to Park Plaza/Plaza Specialty Hospital
Privacy Office at the address listed above. This authorization shall expire 90 days from date, unless sooner revoked, but not retroactive to
the release of information made in good faith; and further, that upon fulfillment of the above-stated purpose, this consent will automatically
expire without my express revocation. I understand that my refusal to sign or revocation of this authorization will not affect the
commencement, continuation, or quality of my treatment at Park Plaza/Plaza Specialty Hospital; except, however, if my treatment is for the
sole purpose of creating health information for disclosure to the recipient identified in this authorization, in which case Park Plaza/Plaza
Specialty Hospital may refuse to treat me if I do not sign this authorization.
I understand that Park Plaza/Plaza Specialty Hospital may, directly or indirectly, receive remuneration for a third party in connection with the
use or disclosure of my health information.
I understand that once Park Plaza/Plaza Specialty Hospital discloses my health information to the recipient, Park Plaza/Plaza Specialty
Hospital cannot guarantee that the recipient will not re-disclose my health information to a third party. The third party may not be required to
abide by this authorization or applicable federal and state laws governing the use and disclosure of my health information.
To the Party Receiving this information: This information has been disclosed to you from the records whose confidentiality is protected by
federal law. Federal regulations (42CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of
the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other
information is not sufficient for this purpose. FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2 AND ALL
OTHER PATIENTS.
Signed_______________________________________________________________________ Date______________________________
Relationship if signed by other than Patient:_____________________________________________________________________________
Witness_____________________________________________________________________
Date______________________________

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