Sample Authorization to Use or Disclosure Protected Health Information – Documents to be Reviewed and Customized Prior to Use
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
This authorization may be used to permit a covered entity (as such term is defined by HIPAA and applicable Texas law) to use or disclose an individual’s protected health information. Individuals completing this form should read the form in its entirety before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their protected health information.
Information regarding patient for whom authorization is made:
Full Name: __________________________________________________________________________
Other Name(s) Used: _____________________________ Date of Birth: _________________________
Address:_____________________________ City:________________ State:______ Zip Code:_______
Phone: (_____)__________________________ Email (Optional): ______________________________
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Information regarding health care provider or health care entity authorized to disclose this information:
Name: ______________________________________________________________________________
Address:_____________________________City:_______________ State:________ Zip Code:_______
Phone: (_____)__________________________ Fax: (_____)__________________________________
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Information regarding person or entity who can receive and use this information:
Name: ______________________________________________________________________________
Address:_____________________________City:_______________ State:________ Zip Code:_______
Phone: (_____)__________________________ Fax: (_____)__________________________________
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Specific information to be disclosed:
□ Medical Record from (insert date) ___________________ to (insert date) ___________________
□ Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records received from other health care providers.
□ Other: ____________________________________________________________________________
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Include: (Indicate by Initialing)
________ Drug, Alcohol or Substance Abuse Records
________ Mental Health Records (Except Psychotherapy Notes)
________ HIV/AIDS-Related Information (Including HIV/AIDS Test Results)
________ Genetic Information (Including Genetic Test Results)
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Reason for release of information:
(Choose all that Apply)
□ Treatment/Continuing Medical Care
□ Personal Use
□ Billing or Claims
□ Insurance
□ Legal Purposes
□ Disability Determination
□ School
□ Employment
□ Other (Specify): ___________________
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The individual signing this form agrees and acknowledges as follows:
(i) Voluntary Authorization: This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits (as applicable) will not be conditioned upon my signing of this authorization form.
(ii) Effective Time Period: This authorization shall be in effect until the earlier of two (2) years after the death of the patient for whom this authorization is made or the following specified date: Month: ________ Day: ________ Year: _________.
(iii) Right to Revoke: I understand that I have the right to revoke this authorization at any time by writing to the health care provider or health care entity listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
(iv) Special Information: This authorization may include disclosure of information relating to DRUG, ALCOHOL and SUBSTANCE ABUSE, MENTAL HEALTH INFORMATION, except psychotherapy notes, CONFIDENTIAL HIV/AIDS-RELATED INFORMATION, and GENETIC INFORMATION only if I place my initials on the appropriate lines above. In the event the health information described above includes any of these types of information, and I initial the corresponding lines in the box above, I specifically authorize release of such information to the person or entity indicated herein.
(v) Signature Authorization: I have read this form and agree to the uses and disclosure of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws.
SIGNATURES:
Patient/Legal Representative: _______________________________________ Date:________________
If Legal Representative, relationship to Patient: _______________________________________________
Witness (optional): ______________________________________________ Date: ______________
A minor individual's signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment.
Signature of Minor (if applicable): ____________________________________ Date: ________________
NOTICE: This sample Authorization to Use or Disclose Protected Health Information was prepared by the Texas- based law firm of Jackson Walker, L.L.P. Any questions regarding this material are subject to the following paragraph and should be directed to your own legal counsel or to Jeffery Drummond at (214) 953-5781. The Texas Medical Association (TMA) has no responsibility for the content of this material and makes no representation regarding the accuracy, currency, or completeness of this information.
Jackson Walker, L.L.P. and TMA provide this information as a commentary on legal issues with the understanding that it is not intended to provide advice on any specific legal matter. Due to the specific circumstances of a particular medical practice, some providers may be subject to other requirements not covered by the provisions of this document (for example, certain covered entities dealing with substance abuse treatment services will also be subject to the requirements of 42 CFR Part 2 disclosure restrictions), and should consult their own attorney. This information should NOT be considered legal advice and receipt of it does not create an attorney- client relationship. This is not a substitute for the advice of an attorney. Jackson Walker, L.L.P. and TMA provide this information with the express understanding that 1) it does not create an attorney-client relationship with you, 2) neither TMA, Jackson Walker, L.L.P. nor its attorneys are engaged in providing legal advice to you, and 3) that the information is of a general character.
Although Jackson Walker, L.L.P. and TMA have attempted to present materials that are accurate and useful, some materials may be outdated, and Jackson Walker, L.L.P. and TMA shall not be liable to anyone for any inaccuracy, error or omission, regardless of cause, or for any damages resulting therefrom. Any legal forms are only provided for the use of physicians in consultation with their attorneys. You should not rely on this information when dealing with personal legal matters; rather, legal advice from retained legal counsel should be sought. Additional statements may be necessary in the authorization form for certain uses and disclosures of protected health information that involve financial remuneration.
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