Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
Regarding (Patient Name)*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Name of Program/Person Authorized to Disclose/Receive/Exchange Information*
Email Address of Authorized Program/Person
Phone Number of Authorized Program/Person
Please enter a valid phone number.
Fax # (if applicable) of Authorized Program/Person
Please enter a valid phone number.
Information to be Disclosed*

Confidential health information related to treatment, assessment, case management, and other aspects of your care.Information necessary for payment or billing purposes (e.g. parent of adult patient paying for services).
Authorization to Release Information:

By signing this form, you authorize the ongoing use and exchange of the information selected above between your provider, their practice, and the previously named third-party individual or organization.

Form of Disclosure: You understand that information may be released verbally, in paper format, or electronically as deemed appropriate by the provider and their practice as well as consistent with applicable law.

Voluntary Authorization: You understand this authorization to release information is voluntary, and refusal to sign will not affect your ability to obtain treatment from your provider.

Effective Time Period: This authorization will expire in the event that you are no longer a patient of the practice, effective at the time of termination of services. You have the right to revoke this authorization at any time. You agree to do so in writing and present my written revocation to the individual or organization releasing information. You understand the revocation will not apply to information already released in response to this authorization or that is otherwise permitted by law without my specific authorization or permission, including disclosures to other covered entities as provided by Texas Health and Safety Code §181.154(c) and/or CFR §164.506(a)(1).

Revocation: You understand that you have a right to revoke this authorization in writing to the clinician or to the custodian of records. You further understand that a revocation of the permission is not effective to the extent that action has been taken in reliance on the authorization.

Signature Authorization:

By signing below, you acknowledge that you have read this form and agree to the uses and disclosure of the information as described. If you have questions, you are encouraged to contact us via our website or by contacting your scheduler. By signing, you agree that you have been provided the opportunity to ask questions and fully understand and consent. You also attest that you have the full right to provide this authorization.
Signature*
Printed Name (please type below)
Should be Empty: