HIPAA Authorization Form - Texas

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Texas — General HIPAA Authorization

Complete every required field. Do not use this form for a specially protected
record or purpose until Section 1 identifies and clears the additional law
and form. A blank, expired, revoked, impermissibly combined, or materially
false authorization is not valid under 45 C.F.R. § 164.508.

1. RELEASE ROUTING — COMPLETE BEFORE SIGNATURE

1.1 Person and record

1.2 Applicable route

Privacy officer or counsel routing decision: [________________________________]

Additional form or authority attached: [________________________________]

2. PERSON OR CLASS AUTHORIZED TO DISCLOSE

I authorize the following person(s) or class of persons to make the use or
disclosure described in this form:

The description must identify the discloser specifically enough for the
releasing entity to determine who is authorized.

3. INFORMATION AUTHORIZED FOR USE OR DISCLOSURE

Describe the information in a specific and meaningful fashion. Do not use
“all records” unless that scope is intended, legally permitted, and approved.

Provider, facility, plan, or source: [________________________________]

Date range: [__/__/____] through [__/__/____]

Records included

• ☐ Billing records
• ☐ Medication list
• ☐ Laboratory results
• ☐ Diagnostic imaging and reports
• ☐ History and physical
• ☐ Progress or office notes
• ☐ Operative/procedure reports
• ☐ Discharge summary
• ☐ Immunization records
• ☐ Other specifically described information: [________________________________]

Records excluded

[____________________________________________________________]

Additional Texas physician-record description, if applicable: [________________________________]

4. PERSON OR CLASS AUTHORIZED TO RECEIVE

I authorize disclosure to:

For physician records governed by Tex. Occupations Code § 159.005, the written
consent must identify the person to whom the information is released.

5. PURPOSE

Select or describe each purpose:

• ☐ At my request
• ☐ Continuing care
• ☐ Insurance or benefits matter
• ☐ Legal matter identified as: [________________________________]
• ☐ Other specific purpose: [________________________________]

If the individual initiated the authorization and elects not to state another
purpose, “at my request” may be used. Special-purpose authorizations require
separate review.

6. EXPIRATION

This authorization expires on one completed date or event related to me or the
purpose of the disclosure:

☐ Date: [__/__/____]

☐ Event: [________________________________]

Revocation is addressed separately in Section 7. Do not use revocation as a
substitute for the required expiration date or event.

7. RIGHT TO REVOKE

I may revoke this authorization at any time by sending a written revocation to:

Name/office: [________________________________]

Address, email, or approved delivery route: [________________________________]

Revocation will not affect action already taken in reliance on this
authorization. If this authorization was obtained as a condition of insurance
coverage, revocation is also subject to any other law giving the insurer a
right to contest a claim or the policy.

For physician records governed by Tex. Occupations Code § 159.005, withdrawal
does not affect information disclosed before written notice of withdrawal.

8. CONDITIONING NOTICE

Select the accurate statement:

☐ The covered entity may not condition treatment, payment, enrollment, or
eligibility for benefits on whether I sign this authorization.

☐ The covered entity may condition the following service or eligibility on
this authorization under 45 C.F.R. § 164.508(b)(4):
[________________________________]. If I refuse to sign, the consequence is:
[________________________________].

Do not select the second option without privacy-officer or counsel approval of
the exact regulatory exception.

9. REDISCLOSURE NOTICE

Information disclosed under this authorization may be redisclosed by the
recipient and may no longer be protected by the HIPAA Privacy Rule. Other
federal or Texas confidentiality law may continue to restrict the recipient.

10. INDIVIDUAL ACKNOWLEDGMENTS

By signing, I confirm that:

• I have read this authorization and it is written in language I understand;
• the information, discloser, recipient, purpose, and expiration are complete;
• I understand the revocation, conditioning, and redisclosure statements;
• I have had an opportunity to ask questions; and
• I am entitled to a copy of this signed authorization.

This authorization does not create a contract among the individual, releasing
entity, and recipient; does not supply indemnity, damages, attorney fees,
arbitration, forum selection, or a liability cap; and does not authorize
anything prohibited by other law.

11. SIGNATURE

Individual

Signature: __________________________________

Printed name: [________________________________]

Date: [__/__/____]

Personal representative — complete only if applicable

Representative signature: __________________________________

Printed name: [________________________________]

Authority to act for the individual: [________________________________]

Supporting document reviewed/attached: [________________________________]

Date: [__/__/____]

The releasing entity must verify the representative's authority and whether
the representative may authorize release of every identified record.

12. RELEASING ENTITY USE

Reviewed by: [________________________________]

Date: [__/__/____]

Disclosure log/reference: [________________________________]