1-MEDICAL RELEASE FORM

AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby authorize (Previous Pediatricians office)*
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone*

Area CodePhone Number
Fax
Patient Name*
Patient Date of Birth*

MonthDayYear
Date
Patient Address*
Patient Phone*

Area CodePhone Number
Information to be released:

Complete ChartHistory & PhysicalOperative RecordsPathology ReportsLab RerpotsConsultation ReportsRadiology/Xray ReportER ReportsProgress NotesVaccination RecordDischarge SummariesBilling Records ONLYOther
Reason for release

Transfer of careTreatment/consultPatient requestAttorneyPatient requestBilling of ClaimsOther
Substance use/abuse treatment, psychiatric, genetic testing and/or HIV/AIDS records release: Federal and State law requires specific & separate authorization from patients to release sensitive information. I understand that if my medical or billing record contains information in reference to any of the above categories, I must specifically agree to its release by checking the appropriate box (TX HB 300).
Substance abuse

YesNo
Psychiatric care

YesNo
Genetic testing

YesNo
HIV/AIDS testing treatments

YesNo
Time limit and right to revoke:

This consent is subject to revocation at any time except to the extent that the action has been taken thereon. This authorization & consent will expire one year from the date of authorization written below. I understand that the recipient of my health information may be charged for the service of releasing medical information. Your health care (or payment for care) will not be affected by whether or not you sign this authorization.

Authorization & re-disclosure:

Once your health care information is released, re-disclosure of your health care information by the recipient may no longer be protected by law. I understand that this authorization is voluntary and I may refuse to sign it, however, an unsigned authorization cannot be completed by our office. I authorize the medical facility to use and disclose the protected health information as specified above. I further understand that a fee may be charged for the reproduction of records. A copy or fax of this authorization is as valid as the original.
Signature of Patient*

Clear
Relationship to Patient*
Printed Name*
Date Signed

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION