Patient Auth Form Release - Rheumatology Associates

PATIENT AUTHORIZATION FORM TO RELEASE CONFIDENTIAL HEALTHCARE INFORMATION

This authorization shall be in force and effect until I revoke it, at which time this authorization to use or disclose this IIHI (Individually Identifiable Health Information) and PHI (Protected Health Information) expires. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at:8144 Walnut Hill Lane, Suite 800, Dallas, Texas 75231

The information may include information about HIV, AIDS, alcohol use, drugs, and mental health. I do not have to sign this authorization to receive treatment from Rheumatology Associates. I have the right to refuse to sign this authorization. When my information is used or disclosed according to this authorization, it may be subject to
redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule.

I authorize Rheumatology Associates to use and/or RELEASE certain protected health information (PHI) about me to:

Click here to look up Doctor's Information

Doctor’s First Name:	Doctor’s Last Name:
Doctor’s Phone#:	Address :
Specialty:
Patient’s Name:	Date of Birth:
Rheumatology Associates Doctor:
This authorization permits Rheumatology Associates to use and/or release the following::
Full Medical Record:	Progress Note:
Laboratory:	Imaging/Radiology:
Other:
Individual/patient requests for medical records, please select the method of communication:
Mail Address:
Fax:	Email:
Signed by:
Signature of Patient or Legal Guardian Relationship to Patient
Patient’s Name:	Date:
Print Name of Patient or Legal Guardian:

PATIENT/GUARDIAN TO BE PROVIDED WITH A SIGNED COPY OF AUTHORIZATION

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RHEUMATIC DISEASES

ARTHRITIS FOUNDATION

METROPLEX CLINICAL RESEARCH CENTER

NATIONAL LIBRARY OF MEDICINE

RESOURCES

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