Texas Release of Information

Genesis Counseling Center Release or Exchange of Protected Health Information
Name of Client
Client's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
1. Please check one of the following:
2. I authorize Genesis Counseling Center to (Check ALL that apply)
Name of Person (Spouse, Teacher, Healthcare Provider, Caseworker, Etc.) To Release, Receive, and/or Exchange Information To, From, With
Organization
Phone Number for Person/Organization
Format: (000) 000-0000.
Fax Number for Person/Organization
Format: (000) 000-0000.
3. Type of Release: (check all that apply)
Other
4. Release will remain valid one year from today's date or unless revoked sooner in writing below:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearOptional Expiration Date
5. Patient Authorization: By Signing this release, I understand and agree to the following:
Signature of Client or Personal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed name of Client or Personal Representative and Relationship to Client
Phone number
Your Phone NumberFormat: (000) 000-0000.
Note on Release of Health Records: An individual/legally authorized representative has a legal right to release information to whomever is specified on the Release of Information Authorization (to healthcare providers, family members, school, etc The records of your treatment will contain confidential information about you, and the information in the records can be misinterpreted or upsetting to lay readers. If you request a copy of your records in writing, we will provide them to you upon payment of the records fee unless such access is determined by the mental health provider to be harmful to the individual's physical, mental, or emotional health. If records are not released, a letter of explanation will be provided by your health care provider. We have determined that a reasonable, cost-based fee for providing a printed copy of your records will be $25.00 plus $0.50 per page up to 50 pages, thereafter $0.25 per page. The actual cost of shipping or mailing records will be an additional fee. For electronic records requests the fee shall be $25.00 for 500 pages or less, and $50.00 for more than 500 pages. Under Texas Law, Genesis is not required to provide copies of requested records until the records fee is paid in full.
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Genesis Counseling Center Release or Exchange of Protected Health Information