Release Of Information Form

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION Developed for Texas Health & Safety Code § 181.154(d)

effective June 2013
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 as defined by HIPAA and Texas Health & 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.
NAME OF PATIENT OR INDIVIDUAL
Last Name:*
First Name:*
Middle Name:
Other Name(S) Used
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Birth Date*

MonthDayYear
Email*

Confirmation Emailexample@example.com
Phone Number*

Area CodePhone Number
Alt Phone Number

Area CodePhone Number
I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION:
Person/Organization Name*
Person/Organization Name
Person/Organization Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email*

Confirmation Emailexample@example.com
WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?
Person/Organization Name *
Person/Organization Name
Address *

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax Number (***Impireum's official fax number only***)*

Area CodePhone Number
Reason For Disclosure (Choose only one option)*

Treatment/Continuing Medical CarePersonal UseBilling or ClaimsInsuranceLegal PurposesDisability DeterminationSchoolEmploymentOther
What Information Can be disclosed? Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first bo*

All health informationPhysician's OrdersProgress NotesPathology ReportsHistory/Physical ExamPatient AllergiesDischarge SummaryBilling InformationPast/Present MedicationsOperation ReportsDiagnostic TestRadiology Reports & ImagesLab ResultsConsultation ReportsEKG/Cardiology ReportsOther
Your initials are required to release the following information:
Mental Health Records (excluding psychotherapy
Initials
Drug, Alcohol, or Substance Abuse Records
Initials
Genetic Information (including Genetic Test Results)
Initials
HIV/AIDS Test Results/Treatment
Initials
EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reach-ing the age of majority; or permission is withdrawn; or the following specific date (optional):

MonthDayYear
Signature of Individual or Individual's Legally Authorized Representative*
DATE:*

MonthDayYear
Date
Hour MinutesAM/PM Option
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 ***Name of Legally Authorized Representative (if applicable): If representative, specify relationship to the individual

GuardianParent of minorOther
SIGNATURE:*
DATE:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Important Information About the Authorization to Disclose Protected Health Information Developed for Texas Health & Safety Code § 181.154(d) effective June 2013*
Should be Empty:

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION Developed for Texas Health & Safety Code § 181.154(d)

NAME OF PATIENT OR INDIVIDUAL

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION:

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Your initials are required to release the following information: