Hipaa Form - Authorization For The Use And Disclosure Of Protected Health Information - Medical School

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Patient’s Name: ___________________________________________________
Birth date: ________________________________________________________
Authorization for the Use and Disclosure of Protected Health Information (HIPAA Release Form)
The next of kin of the deceased _____________________________________________ request and direct to release the
decedent’s medical records to the Department of Pathology and Laboratory Medicine at The University of Texas Medical
School at Houston.
This authorization permits the above provider to disclose the following clinical records:
____
All of the decedent’s clinical records that the provider has in his or her possession, including information relating
to any medical history, mental or physical condition and any treatment received by me; or
____
All of the decedent’s health care information described above except for the following.
_____________________________________________ (specifically identify)
____
Only the following records or types of records (insert dates of treatment, type of treatment or other designation)
_____________________________________________
The next of kin understand that the records used and disclosed pursuant to this authorization form may include information relating
to: Human Immunodeficiency Virus (“HIV”) infection or Acquired Immunodeficiency Syndrome (“AIDS”); treatment for or
history of drug or alcohol abuse; or mental or behavioral health or psychiatric care.
The next of kin understand that copies of the records indicated above will be: (check one or more as applicable)
_____
Sent to:
Name of Recipient: _________________________________________
Name of Company: _________________________________________
Address: _________________________________________________
State: ___________ Zip Code: ________________________________
_____
Faxed to:
Name of Recipient: _________________________________________
Name of Company: _________________________________________
Fax Number: ______________________________________________
Confirmation Telephone Number: _____________________________
_____
Made available
Name of Recipient: _________________________________________
to:
Confirmation Telephone Number: _____________________________
The next of Kin understand that to the extent any Recipient of this information, as identified above, is not a “covered entity” under
Federal or Texas privacy law, the information may no longer be protected by Federal and Texas privacy law once it is disclosed to
the Recipient and, therefore, may be subject to re-disclosure by the Recipient. The next of kin understand that the purpose(s) of
the requested use and disclosure is to investigate more fully the central nervous system and possible reasons for this patient’s
dementia.
The next of kin understand that the next of kin may revoke this authorization in writing at any time except to the extent that the
covered entity has already relied on this authorization. I understand that I may revoke this authorization by sending or faxing a
written notice to the UT Outreach lab at 6431 Fannin St, MSB 2.008, Houston, TX 77030, Phone 713-500 -5258 Fax 713-500-
0783 stating my/our intent to revoke this authorization.
Unless otherwise revoked, this authorization will expire on the 180th day of the signing or as otherwise specified
below:___________________________________________________________________________________________________
_________________________________________________________________________________________________________
Signature of Decedent’s Next of Kin:________________________________________________________Date: _____________
Printed Name of Decedent’s Next of Kin________________________________________________________________________

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