Authorization for Release of Patient Information

I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected. I understand that the specified information to be released may include, but is not limited to: history, diagnosis, and/or treatment of drug or alcohol abuse, mental illness, or communicable diseases, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS).

I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for participation in research programs, or authorization of the release of testing results for pre-employment purposes. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon this authorization. I understand I may be charged a fee for copies of my medical records according to Texas Hospital Licensing Law. Please see a Health Information Management employee for pricing information.

This authorization will expire 180 days from the date of my signature unless I revoke the authorization prior to that time or unless otherwise specified by date, event or condition as follows: