Medical records are protected by the Health Information Portability and Accountability Act known as HIPAA
This form can not be used to release medical records that include
- Mental health treatment information
- Drug, Alcohol, or Substance abuse
- Genetic information
- HIV/AIDS test results treatment
This form can not be used for minors' records that include
- Sexually Transmitted Disease
- Reproductive care
- Drug, alcohol, or substance abuse
- Mental health treatments (See Tex. Fam. Code 32.003)
This authorization for the release of medical records is active until
- A minor reaches the age of twenty-one.
- The patient dies.
- Written authorization is withdrawn in writing.
I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named “Release Protected Health Information To.”
I understand that prior actions taken to release this authorization by entities that had permission to access my health information will not be affected.
Signature Authorization: I have read this form and agree to its uses and disclosures as described. I understand that refusing to sign this form does not stop the disclosure of health information that is permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code 181.154c and/or 45C.F.R 164.502a1.