Patient Auth Form Request - Rheumatology Associates

PATIENT AUTHORIZATION FORM TO REQUEST CONFIDENTIAL HEALTHCARE INFORMATION

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

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 request the following:
Full Medical Record:	Progress Note:
Laboratory:	Imaging/Radiology:
Other:
If possible, please send the records electronically. If not, please fax 214-540-0701.
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.
Signed by:
Patient’s Name:	Date:
Print Name of Patient or Legal Guardian:

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

Dallas · Arlington · Duncanville · Flower Mound · Frisco · Grapevine · Irving · North Richland Hills · Plano · Rockwall