AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
IN ACCORDANCE WITH 45 CFR § 164.508-HIPAA
Approved for use by the San Antonio Bar Association and Bexar County Medical Society
I hereby authorize_____________________________ to disclose my Protected Health Information (PHI) as contained in the
records maintained by _________________________, including but not limited to highly confidential information concerning communicable diseases, HIV, AIDS, psychiatric, chemical or alcohol dependency, laboratory test results, or any other medical treatment. This authorization does/does not [please circle selection] include psychotherapy notes.
PATIENT IDENTIFICATION INFORMATION
Account or medical record number __________________________
Patient’s name ___________________________________________________________________
Last First Middle
Social Security No. ____________________________________ Date of Birth ___________________________________
Name and address of recipient: _____________________________________________________________________________
The release of the materials listed is being authorized for use as evidence in a legal proceeding involving this patient. You understand that such information cannot be released without the patient’s specific consent. You are authorized to comply with an original or copy of this document.
DESCRIPTION OF INFORMATION TO BE RELEASED
The matters to be released pursuant to this authorization are as follows: any and all medical or reports, x-rays (if requested), diagnostic studies, laboratory slides (if requested), clinical abstracts, histories, charts, admission sheet, system history or system review, summary sheet, medical service sheet, nurse’s notes, discharge notes, chronological survey, consultant reports, any patient records not located in the medical record library (such as emergency room records), any counseling records, and any correspondence, including any handwritten or typed notes of or from any nurse, doctor, physician, surgeon, or any other person, and any other information, documents and opinions relevant to past, present and future, physical, mental and/or emotional conditions, treatment, or hospitalization.
This authorization includes the release of documents in your possession whether or not created in your office or by another healthcare provider.
I understand that this authorization will expire on ___________ or 180 days from the date of this signed authorization, whichever comes first.
Date
I understand that the information released in response to this authorization is subject to disclosure to other parties, and that any other person, firm or entity that releases materials pursuant to this authorization is released from any liability that might otherwise result from this information.
I understand that I have the 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 physician or appropriate provider. I understand that the revocation will not apply to information that has already been released in response to this authorization.
I understand authorization for the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment. I further understand that my healthcare and the payment of my healthcare will not be affected if I do not sign this form.
You are authorized to comply with an original or copy of this authorization dated on this the _______ day of
___________________________, 20______.
____________________________________________________________ ___________________________
Patients or patient’s – representative (including their relationship to patient) Date
or patient’s guardian (if the patient is a minor or incapacitated adult)
Sun Research Institute · 303 Quincy St Suite 101 · San Antonio, TX 78215 · Ph# 210-227-1289 · FAX# 210-227-4100
