I hereby authorize the Hospital marked below to release records to the recipient designated below.
Las Palmas Medical Center
Del Sol Medical Center
1801 N. Oregon, El Paso, Texas 79902 10301 Gateway West, El Paso, Texas 79925
Ph: 915-521-1389 Fax: 915-599-4145 Ph: 915-263-5656 Fax: 915-599-4448
Date Request Completed/Faxed:
Total Pages Released:
Request Completed By:
Section A: This section must be completed for all Authorizations
PATIENT INFORMATION
Patient’s Name:
Patient’s Phone:
Date of Birth:
Last 4 digit SSN
(optional):
Dates of Treatment Requested:
All Pertinent Records includes those listed below
Consultation
History and Physical Report
Pathology Report
Discharge Summary
Clinical/Laboratory Report
Problem List
Emergency Room Report
Medicine List
Radiology Report
EKG/EEG Report
Operative Report
RECIPIENT INFORMATION
Recipient’s Name:
Recipient’s Address:
City: State: Zip:
Recipient’s Phone:
Recipient’s Fax
(for releases to medical providers ONLY):
Email
(for releases to email):
Purpose of disclosure: At the request of the individual; or
Other 3rd party recipient (please specify purpose):
Request Delivery (If left blank, a paper copy will be provided):
Paper Copy
Electronic Media, if available
Encrypted Email
Unencrypted Email
There is some level of risk that a third party could see your information 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.
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).
This authorization will expire after 180 days or on the following (please choose only one):
Expiration Date: Expiration Event:
Is this request for No, then you may check as many items below as you need.
psychotherapy notes? Yes, then this is the only item you may request on this authorization. You must submit another authorization for other items below.
Description of information to be used or disclosed
Other Records:
Discharge Instructions
Progress Notes
Labor and Delivery Record
Other:
Specialty Test/Therapy
Physician Orders
For USCDI Release Requests: to include all elements as defined in the United States Core Data for Interoperability. Requires Direct Address or National
Provider Identifier:
All types of information found in the records selected above will be provided (if applicable), including information that may be viewed as sensitive, such as alcohol,
drug abuse, genetic information, psychiatric, HIV testing, HIV results or AIDS information. Specify any information you want to exclude:
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 on this form, for a reasonable copy fee, if I ask for it.
6. I get a copy of this form after I sign it.
Section B: 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 Section B, otherwise skip to Section C.
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
Section C: Signatures
I have read the above and authorize the disclosure of the protected health information as stated.
Signature of Patient/Patient’s Representative: Date:
Print Name of Patient’s Representative: Relationship to Patient:
Email: Para.hscexternalreq@hcahealthcare.com – Phone: (888) 749-7952 – Fax: (469) 484-2006
AUTHORIZATION TO RELEASE PROTECTED
HEALTH INFORMATION (PHI) (1/1)
Rev. 06/2021
