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COLLIN COUNTY HEALTH CARE SERVICES (CCHCS) AUTHORIZATION OF (Collin County Government)

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COLLIN COUNTY HEALTH CARE SERVICES (CCHCS)
AUTHORIZATION OF RELEASE OF PROTECTED HEALTH INFORMATION
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION: Effective March 4, 2010, Revised 5/21/2015
Patient Name (Last, First, Middle) DOB AGE
Male
Female
Address City/State Zip Code
I UNDERSTAND THAT THE PROTECTED HEALTH INFORMATION MAINTAINED BY CCHCS FOR THE PATIENT NAMED ABOVE IS CONFIDENTIAL, PROTECTED BY
HIPAA, AND CANNOT BE DISCLOSED WITHOUT SPECIFIC WRITTEN AUTHORIZATION EXCEPT OTHERWISE PROVIDED BY LAW. I HEREBY VOLUNTARILY
REQUEST AND AUTHORIZE RECORDS TO BE RELEASED AS SHOWN BELOW:
CHECK HERE IF THIS SECTION IS NOT APPLICABLE CHECK HERE IF THIS SECTION IS NOT APPLICABLE
TO: CCHCS, 825 N. McDonald St. #130, McKinney, TX. 75069
Employee Health Clinic; Phone (972) 548-5508, Fax (972) 547-1823
Immunizations Clinic; Phone (972) 548-4744, Fax (972) 547-1812
Comm. Disease Clinic; Phone (972)-548-5500, Fax (972) 547-1826
Elimination Program; Phone (972) 548-5510, Fax (972) 548-5514
FROM: _______________________________________________________
(Individual, Physician, Hospital, Clinic, Health Department., and/or Region)
Address:___________________________________________________
Phone:_______________________ Fax: ______________________
This request and authorization extends to ONLY :
All medical information pertaining to Patient (Entire medical record)
Employee Health Laboratory Results and X-ray (imaging)
Immunization Record
Lab work
Imaging/Radiology Reports
Statements of charges or payments
Information pertaining to the following condition, injury or treatment:
________________________________________________
Other (Specify): _________________________________________
TO: _______________________________________________________
(Individual, Physician, Hospital, Clinic, Health Department., and/or Region)
Address: ________________________________________________
Phone: _______________________ Fax: ______________________
I request the information below to be delivered:
by Mail by Fax In Person / Pick- Up
FROM: CCHCS, 825 N. McDonald St. #130, McKinney, TX. 75069
Employee Health Clinic; Phone (972) 548-5508, Fax (972) 547-1823
Immunizations Clinic; Phone (972) 548-4744, Fax (972) 547-1812
Comm. Disease Clinic; Phone (972)-548-5500, Fax (972) 547-1826
Elimination Program; Phone (972) 548-5510, Fax (972) 548-5514
This request and authorization extends to ONLY:
All medical information pertaining to Patient (Entire medical record)
Employee Health Laboratory Results and X-ray (imaging)
Immunization Record
Lab work
Imaging/Radiology Reports
Statements of charges or payments
Information pertaining to the following condition, injury or treatment:
________________________________________________
Other (Specify): _________________________________________
***NOTICE TO PERSON OR AGENCY RECEIVING THIS INFORMATION***
This information has been disclosed to you from records whose confidentiality is protected. Laws and regulations prohibit you from making further disclosure of it
without the specific written consent of the person to whom it pertains. CCHCS and the individual/agency named above are hereby released from any legal
responsibility and liability for disclosure of the information as noted above if disclosure is in accordance with this authorization.
T
his authorization is freel
y
g
iven with the understandin
g
that:
Any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization except as otherwise provided by
law. A photocopy or facsimile of this authorization is as valid as the original.
If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be
redisclosed.
Treatment, services, and payment are not a condition of signing this authorization. I may receive a copy of this form after I have signed it.
CCHCS is authorized to furnish the information even though the confidentiality of the information may be protected by Federal or State laws and regulations. This includes any
and all alcohol and/or drug treatment records or psychiatric records and any information related to HIV or sexually transmitted disease testing or results that are in the record,
unless otherwise specified above.
I may revoke this authorization at any time by presenting my written revocation to CCHCS Attention: Privacy Officer, 825 North McDonald, Suite 130, McKinney, TX 75069. I
understand that the revocation will not apply to information that has already been released under this authorization.
This authorization shall be in effect until my written revocation is received by CCHCS or two years after death of the patient, whichever comes first.
I have read this form and agree to the uses and disclosures of the information as described.
Patient Parent / Guardian
Other: ________________________________
/ /
For Office Use Only: Approved
By: _________________________
Date: ______/______/________
Name of Requestor Requestor Signature Requestor’s Relationship to Patient Date
COLLIN COUNTY HEALTH CARE SERVICES (CCHCS) AUTHORIZATION OF RELEASE OF PROTECTED HEALTH INFORMATION
CCHCS AUTORIZACION PARA DIVULGAR INFORMACION PROTEGIDA DE SALUD
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION: Effective March 4, 2010, Revised 05/21/2015
Nombre (Apellido, Primer Nombre) / Name (First, Middle, Last) FDN / DOB
Edad / Age
Masculino / Male
Femenino / Female
Domicilio
/ Address
C
uida
d
/
Estado Codigo
/
Postal
I UNDERSTAND THAT THE PROTECTED HEALTH INFORMATION MAINTAINED BY CCHCS FOR THE PATIENT NAMED ABOVE IS CONFIDENTIAL, PROTECTED BY
HIPAA, AND CANNOT BE DISCLOSED WITHOUT SPECIFIC WRITTEN AUTHORIZATION EXCEPT OTHERWISE PROVIDED BY LAW. I HEREBY VOLUNTARILY
REQUEST AND AUTHORIZE RECORDS TO BE RELEASED AS SHOWN BELOW:
YO ENTIENDO QUE LA INFORMACION PROTEGIDA DE SALUD QUE MANTIENE CCHCS PARA EL PACIENTE MENCIONADO ARRIBA ES CONFIDENCIAL,
PROTEGIDO POR LAS LEYES DE HIPPA (POR SUS SIGLAS EN INGLES), Y NO PUEDE SER DIVULGADO SIN PERMISO ESCRITO EXCEPTO EN CASO(S) QUE SE
PROVEE(N) POR LEY. YO VOLUNTARIAMENTE PIDO Y AUTORIZO LA DIVULGACION DE LA INFORMACION SIGUIENTE:
CHECK IF THIS SECTION DOES NOT APPLY /
MARQUE LA CASILLA SI ESTA SECCION NE SE APLICA
CHECK HERE IF THIS SECTION IS NOT APPLICABLE /
MARQUE LA CASILLA SI ESTA SECCION NE SE APLICA
TO / PARA: CCHCS, 825 N. McDonald St. #130, McKinney, TX. 75069
Employee Health Clinic; Phone (972) 548-5508, Fax (972) 547-1823
Immunizations Clinic; Phone (972) 548-4744, Fax (972) 547-1812
Comm. Disease Clinic; Phone (972)-548-5500, Fax (972) 547-1826
Elimination Program; Phone (972) 548-5510, Fax (972) 548-5514
FROM / DE: ___________________________________________________
(Nombre de Medico, Hospital, Clinica, Departamento de Salud, etc…)
Add. / Domicile:_______________________________________________
Phone / Tele.:______________________ Fax: ______________________
This request and authorization extends to ONLY :
Esta autorización se aplica SOLAMENTE para:
All medical information pertaining to Patient (Entire medical record) / Toda
información médica del Paciente
Employee Health Laboratory Results and X-ray (imaging) / Resultados de
Laboratorio de la Clinica de Empleados y radiografías
Immunization Record / Registro de Vacunas
Labwork / Resultados de Pruebas de Laboratorio
Imaging and Radiology Reports / Radiografías y Reportes de Radiografía
Statements of charges or payments / Pagos o Estado de Cuenta
Information pertaining to the following condition, injury or treatment /
Información sobre la siguiente condición, lesion o tratamiento:
________________________________________________
Other (Specify) / Otro: _____________________________________
TO / PARA: __________________________________________________
(Nombre de Medico, Hospital, Clinica, Departamento de Salud, etc…)
Address / Domicilio:__________________________________________
Phone / Telefono:______________ Fax: ______________________
I request the information below to be delivered by /
Pido que la información abajo que se enviara:
Mail / por Correo por Fax
In Person / Pick-Up / En persona
FROM / DE: CCHCS, 825 N. McDonald St. #130, McKinney, TX. 75069
Employee Health Clinic Immunizations Clinic
Comm. Disease Clinic Elimination Program
This request and authorization extends to ONLY :
Esta autorización se aplica SOLAMENTE para:
All medical information pertaining to Patient (Entire medical record) / Toda
información médica del Paciente
Employee Health Laboratory Results and X-ray (imaging) / Resultados de
Laboratorio de la Clinica de Empleados y radiografías
Immunization Record / Registro de Vacunas
Labwork / Resultados de Pruebas de Laboratorio
Imaging and Radiology Reports / Radiografías y Reportes de Radiografía
Statements of charges or payments / Pagos o Estado de Cuenta
Information pertaining to the following condition, injury or treatment /
Información sobre la siguiente condición, lesion o tratamiento:
________________________________________________
Other (Specify) / Otro: _____________________________________
***NOTICE TO PERSON OR AGENCY RECEIVING THIS INFORMATION***
This information has been disclosed to you from records whose confidentiality is protected. Laws and regulations prohibit you from making further disclosure of it without the specific
written consent of the person to whom it pertains. CCHCS and the individual/agency named above are hereby released from any legal responsibility and liability for disclosure of the
information as noted above if disclosure is in accordance with this authorization.
This authorization is freely given with the understanding that:
Any and all records, whether written, oral or in electronic format, are confidential and cannot be
disclosed without my prior written authorization except as otherwise provided by law. A
photocopy or facsimile of this authorization is as valid as the original.
If the requestor or receiver is not a health plan or health care provider, the released information
may no longer be protected by federal privacy regulations and may be redisclosed.
Treatment, services, and payment are not a condition of signing this authorization. I may
receive a copy of this form after I have signed it.
CCHCS is authorized to furnish the information even though the confidentiality of the
information may be protected by Federal or State laws and regulations. This includes any and
all alcohol and/or drug treatment records or psychiatric records and any information related to
HIV or sexually transmitted disease testing or results that are in the record, unless otherwise
specified above.
I may revoke this authorization at any time by presenting my written revocation to CCHCS
Attention: Privacy Officer, 825 North McDonald, Suite 130, McKinney, TX 75069. I understand
that the revocation will not apply to information that has already been released under this
authorization.
This authorization shall be in effect until my written revocation is received by CCHCS or two
years after death of the patient, whichever comes first.
I have read this form and agree to the uses and disclosures of the information as described.
Esta autorización
se da libremente con el entendido que:
Toda información, sin tener en cuenta si es en forma escrita, electrónica, o verbal, es
confidencial y no puede ser divulgada sin mi permiso en escrito previo excepto en caso(s) que se
provee(n) por ley. Una fotocopia o fax de esta autorización es válida igual como la original.
En caso que la persona o agencia pidiendo esta información no es un proveedor de aseguranza
de salud o no es un proveedor de servicios médicos, es posible que la información divulgada no
sea protegida bajo las leyes de privacidad federales y puede ser divulgada otra vez.
Tratamiento, servicios, y pagos no son condiciones para firmar esta autorización. Yo puedo
recibir una copia de esta forma después de firmarla.
CCHCS tiene autorización de proveer la información aunque la confidencialidad de la
información es protegida por leyes y reglas estatales o federales. Esto incluye toda información
relacionado con tratamiento de alcohol y/o drogas o información sobre tratamiento psiquiátrica, y
cualquier información relacionada con VIH o pruebas o resultados de enfermedades de
transmission sexual, a menos que se indique lo contrario arriba.
Yo puedo revocar esta autorización en cualquier momento por escrito a CCHCS Attention:
Privacy Officer, 825 North McDonald, Suite 130, McKinney, TX 75069. Yo entiendo que la
revocación no se aplica a información que ya fue divulgada bajo esta autorización.
Esta autorización se mantiene en vigencia hasta que CCHCS recibe mi revocación por escrito o
después de dos años de la fecha de fallecimiento, lo que ocurra primero.
He leído la forma y estoy de acuerdo a los usos y divulgaciones de la información como descrito.
Paciente / Patient Padre / Parent
Tutor / Guardian Otro / Other: __________
/ /
For Office Use Only:
A
pproved
By: _________________________
Date: ______/______/________
Nombre de Solicitante Firma de Solicitante Relación de Solicitantes con el Paciente Fecha
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COLLIN COUNTY HEALTH CARE SERVICES (CCHCS) AUTHORIZATION OF (Collin County Government)

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Completed 13 February 2021

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