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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.

Agreed and Approved:

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