Authorization To Release Confidential Information Form - Texas Department Of Agriculture Structural Pest Control Service

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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 records with the consent of the individual or a person authorized to consent for the individual. For example, the
Medical Practice Act states:
See. 5.08(f)(1) 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 an 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 Act, the Mentally
Retarded Persons Act of 1977, ... Chapter 5, Texas Probate Code [guardians of the person or of the estate]; and Chapter II, Texas
Family Code (suits affecting the parent child relationship]; 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
(C) the person to whom the information is to be released.
Further, the Communicable Disease Prevention and Control Act contains the following specific requirements for the release of
information relating to tests for AIDS, the Human Immunodeficiency Virus (MV) and antibodies to MV:
See. 9.03. (d) The authorization prescribed by Subsection (c)(2) of this section must be in writing and signed by the person
tested or a person legally authorized to consent to the test on the person's behalf and must state the persons or entities or
classification of persons or entities to whom the test results may be released disclosed.
The Texas Department of Agriculture Structural Pest Control Service's “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 the statute.
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 Practice Act, the Communicable Disease Prevention and Control Act and certain other statutes, for instance, those
relating to 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 Open Records Act and other statutes give a very limited time
period during which Texas state agencies 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 the 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.

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