502 Madison Oak Drive, Suite 440
San Antonio, TX 78258
Phone: 210 946-1300
Fax: 210 946-1700
September 2017
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
_______________________________ ___________________ ___________________
fo etaD )tnirp( emaN s’tneitaP Birth Acct. # (internal use)
By signing this authorization, I authorize: To release to:
Name _______________________________________ Name _______________________________________
Address: _____________________________________ Address: _____________________________________
City: ________________________ Zip____________ City: ________________________ Zip____________
Phone: ______________________________________ Phone
: ____
__________________________________
the following individually identifiable health information about me:
All Records Radiology Reports Laboratory/Pathology Reports
Progress Notes Operative Reports Financial Records
Other _________________________________________________________________________________________
covering the period(s) of care from (dates) ______________________________to __________________________________.
I understand that information about HIV testing, sexually transmitted disease and/or AIDS diagnosis(es) may be contained in
these records. I understand these records may also reference psychiatric treatment or treatment for substance abuse.
The information will be used or disclosed for the following purpose: ____________________________________.
When requested by the patient, purpose may be listed as “at the request of the ind
ividual.”
The purpose(s) is/are provided so
that I can make an informed decision whether to allow release of the information.
This authorization will expire on _____________, not to exceed 24 months. The information may___ may not _____ be faxed.
I understand that I have a right to inspect and copy my own protected health information to be used or disclosed under this
authorization. The Practice will not receive payment or other remuneration from a third party in exchange for using or
disclosing the PHI. I understand and agree to pay a reasonable copying fee to cover the cost of transfer. I also understand that I
do not have to sign this authorization in order to receive treatment from Women Partners in OB/GYN. In fact, I have the right
to refuse to sign this authorization. When my information is
used or disclosed purs
uant to this authorization, it may be subject to
re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke
this authorization in writing except to the extent that Women Partners in OB/GYN has acted in reliance upon this authorization.
My written revocation must be submitted to the Privacy Officer at the address above.
Signed by: _______________________________ _______________________________
Signature of Patient or Legal Guardian Relationship to Patient
_______________________________ ______
___
______________________
Print Name Legal Guardian if applicable Date Signed
PATIENT/GUARDIAN TO BE PROVIDED WITH A SIGNED COPY OF AUTHORIZATION
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