PATIENT AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
Patient Name: _________________________________
DOB: ______________________
Address: _________________________________
State & Zip Code: _________________________________
This is an authorization under the Privacy Rules of the Health Insurance Portability and Accountability Act of 1956 {45 CFR >< 164.508}. It authorizes ___________________________________ to disclose my medical records to Sun Research Institute for the purpose(s) of medical care.
This authorization is valid until _________________________. The person/people authorized to make this disclosure is/are ________________________________.
Under the Privacy Rules, I have the right to revoke this authorization at any time, and Sun Research Institute must cease using this authorization.
However, Sun Research Institute may complete any actions it initiated prior to my revocation and which rely on my medical records for completion.
I understand that by disclosing my medical records _________________________________
cannot guarantee the recipient will not use or disclose in violation of the Privacy Rules.
I must revoke this authorization in writing and send the revocation to:
SUN RESEARCH INSTITUTE
303 E. Quincy ST., Suite 101
San Antonio, TX 78215
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(210)227-1289 FAX (210) 227-4100
Please print name:_______________________
Patient Signature___________________
Date________________________
