Authorization For Disclosure Of Health Information

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Endocrine & Thyroid Center
7141 Colleyville Blvd, Colleyville, TX 76034, Phone: (817) 410-9993 Fax: (817) 410-9963
Authorization for Disclosure of Health Information
Patient Name: _________________________________________________________________
Date of Birth: _________________________________ Phone: ___________________________
Address: ______________________________________________________________________
City/State: ____________________________________ Zip: _____________________________
I authorize the use or disclosure of the above named individual’s health information
as described below to be released
FROM:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: ____________________________________ Zip: _____________________________
Phone:_______________________________________ Fax: _____________________________
To: Endocrine & Thyroid Center
(Formerly Endocrinology & Reproductive Medicine of Tarrant County)
The information to be used or disclosed is as follows: (include dates where appropriate).
_____ Complete health records
_____ Lab results
_____ Physical exam
_____ X-ray reports
_____ Immunization record
_____ Consultation reports
_____ Other (please specify: _________________________________________________________________________
I understand that the information in my health record may include information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also
include information about behavioral or mental health services and treatment for alcohol and drug abuse.
I am authorizing the use or disclosure of my information for the purpose of: _________________________________
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this
authorization I must do so in writing and present my written revocation to the health information management
department. I understand that the revocation will not apply to my insurance company when the law provides my
insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire
on the following date, event, or condition: _______________________________________________________ .
If I fail to specify an expiration date, event or condition, this authorization will expire in sixty days. I understand that authorizing
the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to
assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I
understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the
information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information,
I can contact: Karen Cohen, Privacy Officer for Endocrine & Thyroid Center.
____________________________________________
__________________________________________________
Signature of patient or legal representative
Date

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