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RELEASE OF MEDICAL INFORMATION TO/FROM PAIN MANAGEMENT
2315 West Ben White Blvd, Austin TX 78704. Phone: (512)326-5440. Fax (512)326-8660.
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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.
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PATIENTS NAME
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First Name
Last Name
Birth Date of Patient
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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
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cellphone number we can reach you
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Area Code
Phone Number
Additional numbers if needed
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Area Code
Phone Number
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PLEASE SELECT PURPOSE OF RECORDS
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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 forms the patient filled out, laboratory and imaging results, financial records, etc. This is very time consuming. We need 12-15 business days to complete this and it can be very costly.
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
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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)
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Instructions on what to do with records (Email, Mail, Pickup, etc)
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RIGHT TO REVOKE AUTHORIZATION:
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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.
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Check
Credit Card
Money Order/Cashiers Check
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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.
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FULL NAME OF PERSON SIGNING ABOVE.
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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).
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