Authorization For Use And Disclosure Of Protected Health Information

Download a blank fillable Authorization For Use And Disclosure Of Protected Health Information in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Authorization For Use And Disclosure Of Protected Health Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby authorize: ___________________________________________ (Facility Name)
Telephone Number ________________________
___________________________________________ (Facility Address)
Fax Number _____________________________
_________________________________________ (Facility City/State/Zip)
Email Address ____________________________
To Release To: _______________________________________________ (Recipient Name)
Telephone Number ________________________
_______________________________________________ (Street Address)
Fax Number _____________________________
________________________________________________ (City/State/Zip)
Email Address ____________________________
The following information from the medical record of:
Patient Name: _________________________________________________ (first, last) Date of Birth: ____________________ (mm/dd/yyyy)
Social Security No: ____________________ Date(s) of Treatment: ____________________________________ Telephone: ______________
Patient Address: _________________________________________________ Email Address: _______________________________________
Information to be released:
Discharge Summary
History & Physical
Operative Record
Pathology Report
Laboratory Reports
Consultation Reports
EKG/ECHO
Blood Type
ER Records
Progress Notes
Radiology Reports
Vaccination Record
Complete Chart
Abstract/Basics
Face Sheet
Itemized Bill
Other (specify):
__________________________________________________________________________
The information specified above is to be released for the following purposes:
Treatment/Consultation
Patient Request
Billing or Claims
Attorney
Social Security
Other (specify):
__________________________________________________________________________
Substance Use/Abuse Treatment, Psychiatric, Genetic Testing, and/or HIV/AIDS Records Release
Federal and State law requires specific authorization from patients to release sensitive information. I understand that if my medical or billing record
contains information in reference to drug, tobacco and/or alcohol use/abuse, psyciatric care, genetic testing, sexually transmitted disease, Hepatitis B or
C testing, HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) testing and/or treatment, and/or other sensitive
information, I must specifically agree to its release by checking Yes or No in the appropriate box. (TX HB 300)
Substance use or abuse treatment…
Yes-Disclose
NO-Do not Disclose.
Yes-Disclose
NO-Do not Disclose.
Psychiatric care and/or mental health records…
Yes-Disclose
NO-Do not Disclose.
Genetic Testing…
Yes-Disclose
NO-Do not Disclose.
HIV/AIDS testing and/or treatment…
Time Limit and Right to Revoke
I understand that this authorization will be valid for 180 days from the date signed to release any records created up to the date of signature unless
revoked prior to that time or unless otherwise specified as follows. Any records created up to the date of this authorization will require a new
authorization. I desire this authorization to be in effect until _____________________ (expiration date/event). Except to the extent that action has
already been taken in reliance on this authorization, at any time I can revoke this authorization by submitting a notice in writing to the facility Privacy
Officer at the above address.
Authorization and Re-disclosure
I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment
of healthcare may not be conditioned on whether I sign this authorization form. I understand that the information disclosed by this authorization may
be subject to re-disclosure by the recipient and will no longer be protected by federal and state privacy regulations. I authorize the medical facility to
use and disclose the protected health information as specified above. I further understand that a reasonable copy fee may be charged for reproduction
of record copies and/or CDs. A copy of facsimile of this authorization is as valid as the original.
Preferred method of Reproduction:
CD
Secure Email
Paper – We will try to accommodate preference where practicable.
___________________________________________________________________________
__________________________
Signature of Patient or Legal Representative
Date
____________________________________________________________________________
Print Form
Authority to sign if not Patient (Documentation may be required)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go