I hereby authorize the use or disclosure of information from the medical record of:
Patient Name _____________________________________________________________________ 
Medical Record # _________________________________________________________________
Date of Birth _______________________  Social Security # ________________________(optional) 
I authorize the following individual or organization to disclose the above named individual’s health information:
________________________________________________________________________________  Address:__________________________________________________________________________
This information maybe disclosed TO and used by the following individual or organization:
_________________________________________________________________________________  Address:___________________________________________________________________________
For the purpose of:__________________________________________________________________
Please release the following: {Note:  list not required by HIPAA}
 ___Entire Record
or: ___Problem List _____________________________________________________                        
 ___X-Ray/Imaging Reports-from (date)________ to (date)_______  
___Progress Notes                              ___X-Ray Films
___History/Physical Exam                    ___Laboratory Results-from (date)__________to (date)_________
___Medication List                                ___EKG Reports
___Immunization Record                       ___Genetic Testing Information
___List of Allergies                               ___Other Diagnostic Reports (Specify)______________________
___Other (Specify)______________________________________
I understand that 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.
___Yes, I consent to the release of this information.       ___ No, I do not consent to the release of this information.
I understand that the information released is for the specific purpose stated above.  Any other use of this information without the written consent of the patient is prohibited.
I understand that I have a right to 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 individual or organization releasing information.  I understand that the revocation will not apply to information already released in response to this authorization.  I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.  Unless otherwise revoked, this authorization expires upon completion of this request or upon the following date:__________________________________________.
I understand that authorizing the disclosure of this health information is voluntary.  I can refuse to sign this authorization.  I need not sign this form in order to ensure treatment.  I understand that I may inspect or copy 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 re-disclosure and the information may not be protected by federal confidentiality rules.  If I have questions about disclosure of my health information, I can contact ______________________________(insert privacy officer or other office or individuals name or contact information)
____________________________________________________             _______________________________
Signature of Patient or Legal Representative                                                                Date
____________________________________________________             _______________________________
COMPLETE ONLY IF INFORMATION IS TO BE RELEASED DIRECTLY TO PATIENT:I understand that my medical record may contain reports, test results, and notes that only a physician can interpret.  I understand and have been advised that I should contact my physician regarding the entries made in my medical record to prevent my misunderstanding of the information contained in these entries.  I will not hold ___________________________ liable for any misinterpretation of the information in my medical record as a result of not consulting my physician for the correct interpretation.__________________________________________________________     __________________________________________Signature of Patient or Legal Representative                                                                                Date__________________________________________________________     __________________________________________Relationship to Patient (If Legal Representative)                                                                         WitnessRelationship to Patient (If Legal Representative)                                                                         Witness
Date request completed________________       # pages copied____________                Reviewed only____________
Charges $__________________            Cash__________          Check #__________________            Initials____________
* [All articles and any forms, checklists, guidelines and materials are for generalized information only, and should not be reviewed or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony.  They are intended as resources to be selectively used and always adapted – with the advice of the organization’s attorney – to meet state, local, individual organizations and department needs or requirements.  They are distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services.]