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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Developed for Texas Health & Safety Code § 181.154(d)
effective June 2013
Please read this entire form before signing and complete all the
sections that apply to your decisions relating to the disclosure
of protected health information. Covered entities as that term is
dened by HIPAA and Texas Health & Safety Code § 181.001 must
obtain a signed authorization from the individual or the individual’s
legally authorized representative to electronically disclose that indi-
vidual’s protected health information. Authorization is not required for
disclosures related to treatment, payment, health care operations,
performing certain insurance functions, or as may be otherwise au-
thorized by law. Covered entities may use this form or any other
form that complies with HIPAA, the Texas Medical Privacy Act, and
other applicable laws. Individuals cannot be denied treatment based
on a failure to sign this authorization form, and a refusal to sign this
form will not affect the payment, enrollment, or eligibility for benets.
I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH
INFORMATION:
Person/Organization Name _____________________________________________________
Address ____________________________________________________________________
City ______________________________________ State ________ Zip Code __________
Phone (_______)____________________Fax (_______)_____________________________
WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?
Person/Organization Name _____________________________________________________
Address ____________________________________________________________________
City ______________________________________ State ________ Zip Code __________
Phone (_______)____________________Fax (_______)_____________________________
SIGNATURE X__________________________________________________________________________ ________________________
Signature of Individual or Individual’s Legally Authorized Representative DATE
Printed Name of Legally Authorized Representative (if applicable): ____________________________________________________________________
If representative, specify relationship to the individual: ¨ Parent of minor ¨ Guardian ¨ Other ________________________________
A minor individual’s signature is required for the release of certain types of information, including for example, the release of information related to cer-
tain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, e.g., Tex. Fam.
Code § 32.003).
SIGNATURE X__________________________________________________________________________ ________________________
Signature of Minor Individual DATE
NAME OF PATIENT OR INDIVIDUAL
______________________________________________________________
Last First Middle
OTHER NAME(S) USED _________________________________________
DATE OF BIRTH Month __________Day __________ Year______________
ADDRESS _____________________________________________________
______________________________________________________________
CITY ____________________________STATE_______ ZIP______________
PHONE (_____)______________ ALT. PHONE (_____)_________________
EMAIL ADDRESS (Optional): ______________________________________
EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reach-
ing the age of majority; or permission is withdrawn; or the following specic date (optional): Month _________ Day __________ Year _________
RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this au-
thorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that
prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.
SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I un-
derstand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that
is otherwise permitted by law without my specic authorization or permission, including disclosures to covered entities as provid-
ed by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursu-
ant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
REASON FOR DISCLOSURE
(Choose only one option below)
¨ Treatment/Continuing Medical Care
¨ Personal Use
¨ Billing or Claims
¨ Insurance
¨ Legal Purposes
¨ Disability Determination
¨ School
¨ Employment
¨ Other ________________________
WHAT INFORMATION CAN BE DISCLOSED? Complete the following by indicating those items that you want disclosed. The signature of a minor
patient is required for the release of some of these items. If all health information is to be released, then check only the rst box.
¨ All health information ¨ History/Physical Exam ¨ Past/Present Medications ¨ Lab Results
¨ Physician’s Orders ¨ Patient Allergies ¨ Operation Reports ¨ Consultation Reports
¨ Progress Notes ¨ Discharge Summary ¨ Diagnostic Test Reports ¨ EKG/Cardiology Reports
¨ Pathology Reports ¨ Billing Information ¨ Radiology Reports & Images ¨ Other________________
Your initials are required to release the following information:
______Mental Health Records (excluding psychotherapy notes) ______Genetic Information (including Genetic Test Results)
______Drug, Alcohol, or Substance Abuse Records ______ HIV/AIDS Test Results/Treatment
Page 1 of 2
Made fillable by eForms
IMPORTANT INFORMATION AbOUT THE AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Developed for Texas Health & Safety Code § 181.154(d)
effective June 2013
Denitions - In the form, the terms “treatment,” “healthcare operations,” “psychotherapy notes,” and “protected health informa-
tion” are as dened in HIPAA (45 CFR 164.501). “Legally authorized representative” as used in the form includes any person
authorized to act on behalf of another individual. (Tex. Occ. Code § 151.002(6); Tex. Health & Safety Code §§ 166.164, 241.151;
and Tex. Probate Code § 3(aa)).
Health Information to be Released - If “All Health Information” is selected for release, health information includes, but is not lim-
ited to, all records and other information regarding health history, treatment, hospitalization, tests, and outpatient care, and also
educational records that may contain health information. As indicated on the form, specic authorization is required for the release
of information about certain sensitive conditions, including:
• Mental health records (excluding “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501).
• Drug, alcohol, or substance abuse records.
• Records or tests relating to HIV/AIDS.
• Genetic (inherited) diseases or tests (except as may be prohibited by 45 C.F.R. § 164.502).
Note on Release of Health Records - This form is not required for the permissible disclosure of an individual’s protected health
information to the individual or the individual’s legally authorized representative. (45 C.F.R. §§ 164.502(a)(1)(i), 164.524; Tex.
Health & Safety Code § 181.102). If requesting a copy of the individual’s health records with this form, state and federal law
allows such access, unless such access is determined by the physician or mental health provider to be harmful to the individu-
al’s physical, mental or emotional health. (Tex. Health & Safety Code §§ 181.102, 611.0045(b); Tex. Occ. Code § 159.006(a); 45
C.F.R. § 164.502(a)(1)). If a healthcare provider is specied in the “Who Can Receive and Use The Health Information” section of
this form, then permission to receive protected health information also includes physicians, other health care providers (such as
nurses and medical staff) who are involved in the individual’s medical care at that entity’s facility or that person’s ofce, and health
care providers who are covering or on call for the specied person or organization, and staff members or agents (such as busi-
ness associates or qualied services organizations) who carry out activities and purposes permitted by law for that specied cov-
ered entity or person. If a covered entity other than a healthcare provider is specied, then permission to receive protected health
information also includes that organization’s staff or agents and subcontractors who carry out activities and purposes permitted by
this form for that organization. Individuals may be entitled to restrict certain disclosures of protected health information related to
services paid for in full by the individual (45 C.F.R. § 164.522(a)(1)(vi)).
Authorizations for Sale or Marketing Purposes - If this authorization is being made for sale or marketing purposes and the cov-
ered entity will receive direct or indirect remuneration from a third party in connection with the use or disclosure of the individual’s
information for marketing, the authorization must clearly indicate to the individual that such remuneration is involved. (Tex. Health &
Safety Code §181.152, .153; 45 C.F.R. § 164.508(a)(3), (4)).
Charges - Some covered entities may
charge a retrieval/processing fee and
for copies of medical records.
(Tex. Health & Safety Code § 241.154).
Right to Receive Copy - The
individual and/or the individual’s legally
authorized representative has a right to
receive a copy of this authorization.
Limitations of this form - This authorization form shall not be used for the disclosure of
any health information as it relates to: (1) health benets plan enrollment and/or related
enrollment determinations (45 C.F.R. § 164.508(b)(4)(ii), .508(c)(2)(ii); (2) psychotherapy
notes (45 C.F.R. § 164.508(b)(3)(ii); or for research purposes (45 C.F.R. § 164.508(b)(3)(i)).
Use of this form does not exempt any entity from compliance with applicable federal
or state laws or regulations regarding access, use or disclosure of health informa-
tion or other sensitive personal information (e.g., 42 CFR Part 2, restricting use of
information pertaining to drug/alcohol abuse and treatment), and does not entitle
an entity or its employees, agents or assigns to any limitation of liability for acts or
omissions in connection with the access, use, or disclosure of health information
obtained through use of the form.
The Attorney General of Texas has adopted a standard Authorization to Disclose Protected Health Information in accordance with
Texas Health & Safety Code § 181.154(d). This form is intended for use in complying with the requirements of the Health Insur-
ance Portability and Accountability Act and Privacy Standards (HIPAA) and the Texas Medical Privacy Act (Texas Health & Safety
Code, Chapter 181). Covered Entities may use this form or any other form that complies with HIPAA, the Texas Medical
Privacy Act, and other applicable laws.
Covered entities, as that term is dened by HIPAA and Texas Health & Safety Code § 181.001, must obtain a signed authorization
from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health
information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain
insurance functions, or as may be otherwise authorized by law. (Tex. Health & Safety Code §§ 181.154(b),(c), § 241.153; 45
C.F.R. §§ 164.502(a)(1); 164.506, and 164.508).
The authorization provided by use of the form means that the organization, entity or person authorized can disclose, commu-
nicate, or send the named individual’s protected health information to the organization, entity or person identied on the form,
including through the use of any electronic means.
Page 2 of 2
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Completed 17 December 2020

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