Authorization for Disclosure of Protected Health Information

This completed form authorizes a third party to disclose a patient’s
protected health information to Texas Children’s Pediatrics.
Authorization for Disclosure of Protected Health Information
Patient Contact Information
Name of Patient ____________________________________________
Date of Birth _________________________________________________
Address (City, State, ZIP) _____________________________________
Phone ______________________________________________________
__________________________________________________________
Dates of Service ____________________________________________
Reports to be Disclosed
History and Physical Exam
Consultation Reports
Progress Notes
Radiology Reports
Laboratory Reports
Pathology Reports
Immunization Record
_____
_____
_____
_____
_____
_____
Please indicate those reports that you would like to be disclosed.
Growth Chart
_____
Operative Reports
_____
Billing Claims Forms
_____
Itemized Statement of Charges
_____
All Information
_____
Other _____________________________________________________
_____________________________________________________
Records Released From
Name ____________________________________________________
Phone ______________________________________________________
Mailing Address ____________________________________________
Fax ________________________________________________________
City, State, ZIP _____________________________________________
Records Released To
Name ____________________________________________________
Phone ______________________________________________________
Mailing Address ____________________________________________
Fax ________________________________________________________
City, State, ZIP _____________________________________________
Reason for record release _____________________________________
__________________________________________________________
Authorization
I authorize the third party named in the above section to disclose the protected health information about myself (or the patient) as described above. I
understand:
This authorization expires 180 days from the date of my signature unless I specify otherwise.
Expiration _________________________________________________________________
I may revoke this authorization at any time by notifying Texas Children’s Pediatrics in writing. If I revoke the authorization, I understand that it
will have no affect on actions Texas Children’s Pediatrics took in good faith before receiving the revocation.
The information released may contain information related to AIDS or HIV infection; drug or alcohol abuse; mental or behavioral health or
psychiatric care, except for psychotherapy notes.
Texas Children’s Pediatrics may not condition treatment or payment on my completion of this form.
Texas Children’s Pediatrics reserves the right to verify my identity or guardianship.
Signature _________________________________________________________________
Date ________________________________
Printed Name ______________________________________________________________
Relationship to Patient _______________________________________________________
Thank you for choosing Texas Children’s Pediatrics
Form 10 – September 2012
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