Fillable Instructions for Obtaining Consent to Release Confidential Information (Texas Real Estate Contracts)

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Instructions for Obtaining Consent to Release Confidential Information (Texas Real Estate Contracts)

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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Consent to Release Confidential Medical Information
Release form on reverse
Instructions for Obtaining Consent to Release Confidential Information
Information contained in client records is confidential. With certain exceptions, the release of medical records is prohibited by the
provisions of the Medical Practice Act (Article 4495b, V.T.C.S.). In addition, social, financial, educational and other types of information
in client files may be protected by a constitutional or common law right to privacy. There are civil and criminal penalties for the
unauthorized release of such information.
The Medical Practice Act, the common law and the Constitution permit a health care provider to release these types of information
from an individual's record with the consent of the individual or a person authorized to consent for the individual. For example, the
Medical Practice Act states:
Occupations Code Sec. 159.005(a)(1-5) and (b). Consent for the release of confidential information must be in writing and
signed by the patient, or a parent or legal guardian if the patient is a minor, or a legal guardian if the patient has been adjudicated
incompetent to manage his personal affairs or an attorney ad litem appointed for the patient, as authorized by the Texas Mental
Health Code; the Persons With Mental Retardation Act; Chapter XIII, Texas Probate Code, and Subtitle B Title 5, Family
Code; or a personal representative if the patient is deceased, provided that the written consent specifies the following:
(A) the information or medical records to be covered by the release;
(B) the reasons or purposes for the release; and
(C) the person to whom the information is to be released.
Further, the Communicable Disease Prevention and Control Act (Chapter 81, Health and Safety Code) contains the following specific
requirements for the release of information relating to tests for AIDS, the human immunodeficiency virus (HIV), and antibodies to HIV:
Sec. 81.103(d). An Authorization under this subsection must be in writing and signed by the person tested or the person legally
authorized to consent to the test on the person's behalf. The authorization must state the person or class of persons to whom
the test results may be released or
disclosed.
The "Authorization to Release Confidential Information" form was developed to conform to these statutory requirements.
For this reason, when you are requested to release information from records under your control, the form must be carefully completed
to provide the information required by statute. If you are requested to provide information from a client record to an institution (e.g., a
hospital) rather than an individual, and you do not know the name of the individual within the institution to whom the information is to be
sent, insert the title of the responsible person (e.g., the administrator, medical records librarian, etc.). Do not simply insert the name of
the hospital.
The "Authorization to Release Confidential Information" form must be completed and signed by individual clients when
they request their personal health records be released.
The form may be used to obtain information from other providers and when used for that purpose, it should be completed with
the same concern for the statutory, common law and constitutional requirements. Such attention to detail may ultimately save both
time and effort.
The Medical Practices Act, the Communicable Disease Prevention and Control Act and certain other statutes, for instance, those
relating for mental health and mental retardation information, provide several other exceptions to the rule of confidentiality relating to
medical records.
ANY REQUEST FOR INFORMATION WHICH CANNOT BE ADDRESSED BY THE USE OF THE CONSENT TO RELEASE
CONFIDENTIAL INFORMATION FORM MUST BE REFERRED IMMEDIATELY TO THE OFFICE OF GENERAL COUNSEL FOR
NECESSARY ACTION. Because the Public Information Act and other statutes give a very limited time period during which the agency
must respond to requests for information, any delay in making these referrals may lead to results which are adverse to the agency.
Please review the release form before releasing information. All blanks on the form must be filled in, the form must be read by the
client, and the form must be appropriately signed before the information is released. The client must receive a signed copy of the
authorization.
L-30[1] NEW REVISED 7.7.16
Page 1 of 2
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____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
To the fo
llowing individuals:
___________________________________________________ ________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_______________________________________________________________ _____________________________ _____________
(Signature Date)
Consent to Release Confidential Medical Information
Instructions on reverse
Name: __________________________________________________________________________________________
(Name of client)
Address: ________________________________________________________________________________________
(Street Number, Post Office Box, Route Number) (City) (State) (Zip)
I authorize the following individual:
(Individual, Physician, Hospital, Clinic, Attorney, Counselor, School, etc.)
(Street Number, Post Office Box, Route Number) (City) (State) (Zip)
to release the following specific confidential information:
(Indicate specific information)
☐ Yes ☐ No Developmental Information:
Educational Plan:
(Indicate specific information below)
☐ Yes ☐ No
Financial Information:
(Indicate specific information below)
☐ Yes ☐ No
Legal Information:
(Indicate specific information below)
☐ Yes ☐ No
Medical Information:
(Indicate specific information below)
☐ Yes ☐ No
HIV-Related Information:
(Indicate specific information below)
☐ Yes ☐ No
Psychological Reports:
(Indicate specific information below)
☐ Yes ☐ No
Social History:
(Indicate specific information below)
☐ Yes ☐ No
Other:
(Indicate specific information below)
☐ Yes ☐ No
(Name or Position of Individual/Organization, if any, represented
___________________________________________________________________________________________________________
(Street Number, Post Office Box, Route Number) (City) (State) (Zip)
The information released may be used by the individual, or the organization represented by the individual for the following
purpose(s): (list below)
_________________________________________________________________________________________________
I understand that:
1) I
may
revoke this authorization in
writing
by
contacting
the DSHS office or program
that obtained the
authorization; 2) this authorization
will not affect treatment,
payment, enrollment, or eligibility
for benefits;
and 3) information disclosed
as a result of this authorization could be subject to re-disclosure as authorized by law.
EXPIRATION DATE: This authorization will expire on: (date or event) ___________________________________________.
(if no date or event is stated, expiration is one year from
signature date)
This form ☐ was read by me ☐ was read to me and I understand its meaning. All the blanks were filled in before the form was signed
by me.
(signature)
(Print/Type Name of Person Authorized to Consent to Release of Information)
(Signature of Authorized Person)
(Address) (Telephone) (Date)
PRIVACY NOTIFICATION
With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You
also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more information on Privacy Notification. (Reference:
Government Code, Section 552.021, 552.023, 559.003 and 559.004)
L-30[1] NEW REVISED 7.7.16
Page 2 of 2
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Instructions for Obtaining Consent to Release Confidential Information (Texas Real Estate Contracts)

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Completed 20 April 2021

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