Authorization For Release Of Protected Health Information (Phi)
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1AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI)
1. Release of information from the hospital records of:
_______________________________________
____________________________________
Patient’s Name – Please print
Date of birth or Social Security number
_______________________________________
____________________________________
Date of treatment
Telephone number
2. I hereby authorize Medical City Dallas Hospital to release the following information to:
_________________________________________________________________________________
Doctor, Hospital, Insurance Company, etc. to receive information
____________________________________
__________________ ___________
__________
Street
City
State
Zip
3. For the purpose of: _________________________________________________________________
4.
Information to be released:
Face sheet
Operative report
Laboratory reports
Emergency room records
Pathology report
Radiology reports
History and physical
Physician’s progress notes
EKG, EEG
Discharge summary
Physician’s orders
Nurse’s notes
Consultations
Other (specify): __________________________________________________________________
5.
I understand specific information to be disclosed may include history of Drug or Alcohol Abuse or mental health Treatment,
information concerning communicable diseases such as Human Immunodeficiency virus (HIV), and Immune Deficiency
Syndrome (AIDS), laboratory test result, treatment progress, and any other such related information.
6.
I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it.
This authorization will expire in 180 days from the date of my signature.
7.
Once this information is disclosed to a third party it may be subject to re-disclosure by the recipient and may no longer be
protected by this rule.
8.
There may be a fee for copying medical records, The State of Texas has sets these fees based on the costs for providing this
service.
9.
If you are claiming to be the patient’s legal representative, you must indicate that authority and provide supporting
documentation.
____________________________________________
__________________________
Signature of Patient or Legal representative
Date
____________________________________________
Relationship to Patient
PATIENT IDENTIFICATION
7777 Forest Lane
Dallas, Texas 75230
(972) 566-7070
Authorization for Release of
Protected Health Information (PHI)
*ROI*
*ROI*
MCD01700 (Rev. 7/09)
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