Authorization for the Use and Disclosure of Protected Health Information

1.  I hereby authorize the class of persons identified below to use and disclose protected health information from the record(s) of:

Patient's Name: ___________________________________________
Date of Birth: ______________________________________________
Social Security Number: ___________________________________

Class of persons authorized to disclose PHI (“Persons Authorized to Disclose”):  All hospitals, clinics, physicians, pharmacy records/history and other health care providers that have records of my past health care and treatment.

                                                                       (Facility Name and Address)

2.  Copies of the following records shall be used and disclosed:

___  Complete Medical Records; or
___  Other: ______________________________________________________________________

3.  Dates of Service: From: _______________________ To: __________________________

4.  I understand that the records used and disclosed pursuant to this authorization form may include information relating to: Human Immunodeficiency Virus (“HIV”) infection or Acquired Immunodeficiency Syndrome (“AIDS”); treatment for or history of drug or alcohol abuse; or mental or behavioral health or psychiatric care.

5.  I understand that copes of the records indicated above will be (check one):
____  Sent to:                                                                               ____ Faxed to:

Forester Haynie
1701 N Market Street, Suite 210
Dallas, Texas 75202
Facsimile: (214) 346-5909

6.  I understand that the purpose(s) of the use and disclosure is (are):____________________________

7.  Unless otherwise revoked, I understand that the specific date, event, or condition upon which this authorization expires is: __________________________________________________________________________________________

8.  Any facsimile, copy, or photocopy of this authorization shall be as valid as the original.

9.  I understand that I may revoke this authorization in writing at any time except to the extent that the Persons Authorized to Disclose may have already relied on this authorization. I understand that I may revoke this authorization by sending or faxing a written notice to the Persons Authorized to Disclose stating my intent to revoke this authorization.

10.  I understand that my health care providers may not condition treatment on my completion of this authorization form.

11.  I understand that to the extent the recipient of this information is not a “covered entity” under Federal law, the information may no longer be protected by Federal law once it is disclosed to the recipient and, therefore, may be subject to re-disclosure by the recipient.

12.  I understand that I may inspect and copy the information to be used and disclosed pursuant to this authorization form before I sign this authorization form if I ask to do so.

13.  I understand that this authorization is voluntary and that I may refuse to sign this authorization form.

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Signature Certificate
Document name:
lock iconUnique Document ID: 4c745b563a607db24fad31616e217428c100c958
Timestamp Audit
February 20, 2018 10:56 am CDT Uploaded by Forester Haynie - IP