Authorization For Release of Medical Record Information

Patient Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

Phone 1

Phone 2

Release From

Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Dates and Type of Information to disclose:

History and Physical
Progress Notes – Last 6 months
Lab/X-Rays/Other Study Reports – Last 6 months
Specific Information Requested

The Purpose of disclosure is:

Referral
Continuation of Care (e.g. hospital)
Change of Insurance
Other

RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified.

I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

This information may be disclosed and used by the following organization:

Austin Palliative Care
4107 Spicewood Springs Rd Suite 100
Austin, TX 78759-8645
Main Phone Number: 512-397-3360
Fax Number: 512-343-7107

I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition.

If I fail to specify an expiration date, event or condition, this authorization will expire 1 year from the date signed.

I understand that authorizing the disclosure of this health information is voluntary. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected be federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

I have read the above foregoing Authorization for Release of Medical Record Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization. I acknowledge that I have been provided a copy of the above information in my new patient packet.

Signature of Patient / Parent / Guardian or Authorized Representative

(Guardian or Authorized Representative must attach documentation of such status.)