Substance use/abuse treatment, psychiatric, genetic testing and/or HIV/AIDS records release: Federal and State law requires specific & separate authorization from patients to release sensitive information. I understand that if my medical or billing record contains information in reference to any of the above categories, I must specifically agree to its release by checking the appropriate box (TX HB 300).

Time limit and right to revoke:

This consent is subject to revocation at any time except to the extent that the action has been taken thereon. This authorization & consent will expire one year from the date of authorization written below. I understand that the recipient of my health information may be charged for the service of releasing medical information. Your health care (or payment for care) will not be affected by whether or not you sign this authorization.

Authorization & re-disclosure:

Once your health care information is released, re-disclosure of your health care information by the recipient may no longer be protected by law. I understand that this authorization is voluntary and I may refuse to sign it, however, an unsigned authorization cannot be completed by our office. I authorize the medical facility to use and disclose the protected health information as specified above. I further understand that a fee may be charged for the reproduction of records. A copy or fax of this authorization is as valid as the original.