Mail or fax to: Release of Information 8101 W. Sam Houston Pkway South, Suite 100, Houston TX 77072 Fax (855) 519-9683 Phone (855) 519-9682
Hand delivered authorizations are accepted at the facility where services were provided - Note: Include copy of valid photo ID with Authorization
All sections must be completed for a valid authorization.
Patient Name:
Patient Alias(s):
Recipient’s Name:
Birth Date: Last 4 Digits SSN (optional):
Patient Contact Number:
Recipient’s Phone: Recipient’s Fax:
Recipient’s Address (City, State, Zip):
Request Delivery (If left blank, a paper copy will be provided):
Paper Copy
Electronic Media, if available (e.g., USB drive, CD/DVD)
Encrypted Email
Unencrypted Email
NOTE: In the event the facility is unable to accommodate an electronic delivery as requested, an alternative delivery method will be provided
(e.g., paper copy). There is some level of risk that a third party could see your PHI without your consent when receiving unencrypted electronic
media or email. We are not responsible for unauthorized access to the PHI contained in this format or any risks (e.g., virus) potentially introduced
to your computer/device when receiving PHI in electronic format or email.
Email Address (If email checked above. Please print legibly):
Purpose of disclosure:
Is this request for psychotherapy notes? Yes, then this is the only item you may request on this authorization. You must submit another
authorization for other items below. No, then you may check as many items below as you need.
Description:
Abstract (most common)
Clinical Test(s)
ER Information
Discharge Instructions
Operative Documentation
Physician Dictated Reports
Date(s): Description:
Physician Progress Notes
Physician Orders
Medication Sheets
Entire medical record
Other:
Date(s): Description:
Confidential Information
HIV Testing
HIV & AIDS Documentation
Psychiatric Documentation
Alcohol & Drug Abuse
Documentation
Date(s):
I hereby authorize the Hospital marked below to release records to the recipient party designated above.
Below marked HCA Houston Healthcare Facility:
Clear Lake Medical Center Southeast
Conroe Northwest Specialty Hospital MC
Kingwood North Cypress Tomball
Mainland Pearland West
Corpus Christi Medical Center (+ Campuses)
Rio Grande Regional Hospital
Texas Orthopedic Hospital
The Woman’s Hospital of Texas
Valley Regional Medical Center
This consent shall become invalid and expire 180 days from the date of signature, unless otherwise stated:
Expiration Date: or Expiration Event:
I understand that:
1. I may refuse to sign this authorization and that it is strictly voluntary
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
3.
I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the revocation.
Further details may be found in the Notice of Privacy Practices.
4. If the requester 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.
5. I understand that I may see and obtain a copy of the information described in this form, for a reasonable copy fee, if I ask for it.
6. I get a copy of this form after I sign it.
Unless I specifically mark below that I do not consent, I am expressly consenting to the release of information relating to psychiatric or psychological
testing or treatment, biofeedback training, alcohol and/or drug abuse diagnosis, prognosis and treatment and/or HIV(AIDS) testing and/or results,
genetic information, or such disclosure shall be limited to the following specific types of information: I DO NOT CONSENT
[ ]
Is the request of PHI for the purpose of marketing and/or does it involve the sale of PHI?
If yes, the health plan or health care provider must complete below, otherwise skip to signature.
Yes No
Will the recipient receive financial remuneration in exchange for using or disclosing this information? Yes No
If yes, describe:
May the recipient of the PHI further exchange the information for financial remuneration? Yes No
I have read the above or had it read to me and I authorize the disclosure of the Protected Health Information as stated.
Signature of Patient/Patient’s Representative:
Print Name of Patient’s Representative:
*Authorized representative must submit copies of legal document supporting his or her authority to act on the patient’s behalf.
Date:
Relationship to Patient:
Identification Verified by:
State Issued Photo Identification
Other:
AUTHORIZATION TO RELEASE PROTECTED
HEALTH INFORMATION (PHI) Rev. 03/2019
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