Language
English (US)
Español
RELEASE OF MEDICAL INFORMATION TO/FROM PAIN MANAGEMENT
2315 West Ben White Blvd, Austin TX 78704. Phone: (512)326-5440. Fax (512)326-8660.
Automated DateTime Stamp
IMPORTANT PLEASE REVIEW
Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. Covered entities as that term is defined by HIPAA and Texas Health and Safety Code § 181,001 must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions or as may be otherwise authorized by law. Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.
Back
Next
Save
PATIENTS NAME
*
First Name
Last Name
Birth Date of Patient
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Name of person completing this form (if different than above)
First Name
Last Name
Email of person completing this form
example@example.com
Patients Mailing address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cellphone number we can reach you
*
-
Area Code
Phone Number
Additional numbers if needed
-
Area Code
Phone Number
Back
Next
Save
PLEASE SELECT PURPOSE OF RECORDS
*
Patients Personal Records
Patients Disability Claim
Patients Insurance Claim
Patients Legal Claim
Patients Personal Injury Claim
Patient Needs Records for Referral
Patient Needs Records to continue care with another Pain Doctor
Patient Needs Records for Workers Compensation Claim
Patient Needs Records for Employment Issues
Patients School Records
Other: (fill out below)
If you selected "other", please explain so that we may comply with your request. Due to the sensitive nature of Protected Health Information, we need to understand to whom and for what purpose the patients records are being utilized.
Enter Specific Purpose of medical records above.
Please tell us specifically what you need. Clicking exactly what you need can save the patient on applicable costs.
*
Electronic Version of Patient Chart (Visit notes). This does not include laboratory, imaging, or forms the patient filled out. This is the quickest and cheapest option, and it can be sent electronically. This type of request is very fast. We need 2-15 business days to complete this request.
Entire complete chart including all forms, laboratory and imaging results, financial records, etc. This is very time consuming. We need 12-15 business days to complete and there may be a charge for records.
Other (please specify below)
If other (above), please specify exactly what is needed.
Please acknowledge that your release of record may contain references to Mental Health Records, Drug, Alcohol, and Substance Abuse Treatment, Sexually Transmitted Diseases, Reproductive Health, and HIV testing. If this creates an issue for you, please DO NOT FILL OUT THIS FORM. Contact our office at "paincare@paincaretx.com" for alternate instructions.
*
Yes, I understand
Back
Next
Save
Whom do you authorize the disclosure of protected health information to?
I hereby authorize Pain Management to provide records to the below mentioned party a copy, summary, or narrative, of my medical records of the following confidential information to: (Please state "NONE" if you do not wish to disclose)
*
Instructions on what to do with records (Email, Mail, Pickup, etc)
*
RIGHT TO REVOKE AUTHORIZATION:
*
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 name under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.
EFFECTIVE TIME PERIOD:
Please allow up to 15 business days as required by local and state guidelines to receive records. If there is a charge, How do you prefer to pay for the records service? (Sorry no cash please so that we may track any transactions involving your privacy). We will let you know the exact amount prior to processing.
*
Check
Credit Card
Money Order/Cashiers Check
Other
Back
Next
Save
Signatures and Authorization by Person who has Legal Right to Obtain Records
We Value your Privacy and May Require Additional Proof of Identity and Authority
FULL SIGNATURE :
Signature of Individual or Individual’s Legally Authorized Representative (Parent/Guardian/Designated Power of Attorney, etc). Please upload an attachment proving relationship.
Patients signature (or authorized person)
*
SIGNATURE AUTHORIZATION. I have read this form and agree to the uses and disclosures 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, including disclosures to covered entities as provided by Texas Health & Safety Code § 181,154(c) and/or 45 C.F.R. § 164,502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
FULL NAME OF PERSON SIGNING ABOVE.
*
YOUR FULL NAME WILL BE ADDED TO OUR CHART
RELATIONSHIP OF PERSON SIGNING ABOVE
*
PLEASE WRITE "SELF" IF YOU ARE THE PATIENT. OTHERWISE, PARENT, GUARDIAN, DESIGNATED POWER OF ATTORNEY, ETC. AT OUR DISCRETION, WE MAY REQUEST PROOF OF RELATIONSHIP.
SIGNATURE OF MINOR: 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 (See, e.g. Tex. Fam. Code § 32,003).
Save
Submit
Should be Empty: