HIPAA AUTHORIZATION FORM

ABRAMS ROYAL PHARMACY HIPAA FORM
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 & 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 an insurance or health maintenance organization function, 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 *

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address of Patient*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Patient*
Please enter a valid phone number.
Email of Patient*
example@example.com
Which is your primary store? *
I authorize the following entity to disclose the individual's protected health information

Abrams Royal Pharmacy
8220 Abrams Rd
Dallas, TX 75231
Phone:(214) 349-8000 Fax:(214) 341-7966
Are you requesting your own health records for your own personal use?*

YesNo
Reason for disclosure?*

Personal UseBilling or ClaimsInsuranceLegal PurposesDisability DeterminationSchoolEmploymentTreatmentContinuing Medical CareOther
Who can receive and use the Health Information*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What information can be disclosed?*

All health informationPast/Present MedicationsPhysician's OrdersProgress NotesPathology ReportsHistory/Physical ExamPatient AllergiesDischarge SummaryBilling InformationOperation ReportsDiagnostic Test REportsRadiology Reports and ImagesLab ResultsConsultation ReportsEKG/Cardiology ReportsOther
EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or the following specific date (optional): DateIf the date field listed is left blank, this authorization will expire in one year from the date that it is originally submitted.
RIGHT TO REVOKE: 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 named 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.
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 other covered entities as provided by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.506(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.
Signature of Individual or Authorized Representative

Clear
Date

MonthDayYear
Date
Please Type Name of Legally Authorized Representative (if applicable): Please type full name here
If representative, specify relationship to the individual: Parent of Minor Guardian Other Please list relationship
Should be Empty:

ABRAMS ROYAL PHARMACY HIPAA FORM