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Medical Forms: Authorization For Release of Protected Medical Information Medical Forms Authorization for Release of Protected Medical Information Printed Name: Date of Birth: Address: Home Telephone: Authority to Release Protected Health Information I hereby authorize the release of medical information, identified in this authorization form, and provide such information to: C Bbd AND The information to be released includes the following: Complete health record Discharge summary Progress notes History and physical exam Consultation reports X-ray films/images Laboratory test results X-ray& Image reports Itemized bill Diagnosis&treatment codes Complete billing record Other(specify) Purpose of the Requested Disclosure of Protected Health Information I am authorizing the release of my protected health information. Drug and/or Alcohol Abuse, and/or Psychiatric, and/or Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome(HIV/AIDS) Records Release I understand if my medical or billing record contains information in reference to, psychiatric care, sexually transmitted disease, hepatitis B or C testing, previous drug and/or alcohol abuse and/or other sensitive information, I agree to its release. Check One:❑Yes❑No I understand if my medical or billing record contains information in reference to HIV/AIDS testing and/or treatment I agree to its release. Check One:❑Yes❑No Right to Revoke Authorization Except to the extent that action has already been taken in reliance on this authorization,the authorization may be revoked at any time by submitting a written notice to Thp,QQ&J2QrAtA Claims DeoLat 2103 Research Forest Drive, The Woodlands, TX 77380. Unless revoked,this authorization will expire at which time completion of treatment for the injury or illness has been accomplished. Re-disclosure understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the Health Insurance Portability and Accountability Act of 1996. Signature of Patient or Personal Representative Who May Request Disclosure I understand that I do not have to sign this authorization. However, if health care services are being provided to me for the purpose of providing information to a third-party(e.g.,fitness-for-work test), I understand that services may be denied if I do not authorize the release of information related to such health care services to the third-party. I can inspect or copy the protected health information to be used or disclosed. I hereby release and discharge of any liability and the undersigned will hold Ca&/harmless for complying with this Authorization. Signature: Date: Description of relationship if not patient: