Medical Records Authorization - Texas

TEXAS MEDICAL-RECORDS AUTHORIZATION — PREPARATION PACKET

Do not sign or submit this packet as an authorization. First determine whether the request is a patient-access request, third-party authorization, litigation request, subpoena response, court-order process, or specialized consent. Use the current provider or counsel-approved form.

Texas sensitive-record and authority gate

1. Request and Person Record

2. Current-Authority and Form Gate

☐ Current federal regulations, Texas law, provider instructions, official forms, and proceeding rules were checked.

☐ Pending and recently effective changes were checked.

☐ Every sensitive category uses the required separate or specialized document.

3. Procedural Route

Select one complete route:

☐ Patient or personal-representative access request

☐ Third-party authorization requested by the patient

☐ Authorization for counsel, insurer, expert, or another recipient

☐ Subpoena / discovery request with separate privacy compliance

☐ Court or administrative order

☐ Specialized psychotherapy-notes authorization

☐ Specialized substance-use-disorder consent

☐ Specialized mental-health, minor, deceased-person, genetic, HIV, or other form

☐ Provider’s own current form

Selected form, revision, and source: [________________]

Reason this route applies: [________________]

4. Authority to Act

Identity documents required: [________________]

Authority document attached: [________________]

Conflict, minor-consent, separated-parent, estate, or guardianship issue: [________________]

5. Disclosing Entities

Prepare a separate authorization or request for each entity when its form or record system requires it.

6. Records Scope

Use precise categories and date ranges. Avoid “all records” unless the purpose and minimum-necessary / access analysis support it.

Sensitive-Category Screen

7. Purpose, Recipient, and Use

Specific recipient name and address: [________________]

Purpose stated on operative form: [________________]

Permitted use / proceeding: [________________]

Person authorized to receive electronically: [________________]

Further-disclosure or protective-order controls: [________________]

Records not to be filed publicly: [________________]

Do not add contractual promises, indemnities, fee shifting, or enforcement remedies to an authorization unless separately reviewed and lawful.

8. Expiration and Revocation

Expiration date or event supported by the selected form: [________________]

Revocation method and address / recipient: [________________]

How prior reliance is treated: [________________]

Records or disclosures not affected by revocation: [________________]

No default two-year expiration or universal revocation method applies from this packet.

9. Format, Fees, and Delivery

Sensitive delivery precautions: [________________]

Redaction / minimum record / confidentiality order: [________________]

10. Execution and Submission Control

11. Receipt and Chain-of-Custody Log

Final Counsel Checklist

☐ Correct procedural route and current form selected.

☐ Identity and representative authority verified.

☐ Each disclosing entity, recipient, purpose, record category, and date range is specific.

☐ Psychotherapy, substance-use, mental-health, HIV, genetic, minor, deceased-person, and other sensitive records were separately screened.

☐ Expiration, revocation, conditioning, redisclosure, copy, fee, and signature requirements match the selected form.

☐ Litigation, subpoena, court-order, insurer, agency, and protective-order issues are resolved.

☐ Secure delivery, storage, redaction, and filing controls are complete.

☐ No two-year default, five-day cure, fee award, no-bond injunction, indemnity, force majeure, assignment, or “original for all purposes” term remains.

☐ This packet—not the operative authorization—will remain in counsel’s confidential work file.

☐ Unused options and drafting notes were deleted.