Authorization to Disclose Protected Health Information

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 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(Required)

Name(Required)

First Middle Last

OTHER NAME(S) USED(Required)

DATE OF BIRTH Month

Address(Required)

Street Address City State ZIP / Postal Code

PHONE ( __ ) ALT. PHONE ( __ )

I AUTHORIZE THE FOLLOWING TO USE, DISCLOSE, AND SEND THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION:

Person/Organization Name

Address(Required)

Street Address City State ZIP / Postal Code

Phone(Required)

Fax(Required)

REASON FOR DISCLOSURE

Treatment/Continuing Medical Care

Personal Use

Billing or Claims

Insurance

Legal Purposes

Disability Determination

School

Employment

Other

(Choose only one option below)

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Person/Organization Name	Joan Franklin
Address	2249 Ridge Road
City	Rockwall
State	TX
Zip Code	75087
Phone	469-402-3604
Fax	469-402-3606

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 box.

Untitled(Required)

Untitled

Your initials are required to release the following information:(Required)

Mental Health Records (excluding psychotherapy notes)

Genetic Information (including Genetic TestResults)

Drug, Alcohol, or Substance Abuse Records

HIV/AIDS Test Results Treatment

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): Month Day Year

Date

'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 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.

SIGNATUREX

Signature of Individual or Individual's Legally Authorized Representative Printed Name of Legally Authorized Representative (if applicable):

DATE

If representative, specify relationship to the individual:(Required)

Parent of minor

Guardian

Other

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).

SIGNATUREX

Signature of Minor Individual

DATE