Authorization for Release of Patient Information Name of Patient:* First Last Name of Requestor:* First Last Relationship to Patient*Choose a relationshipLawyerLegal GuardianParentProviderSelfWorkers CompMedical FacilityOther Names Used:Phone Number:*Email Enter Email Confirm Email Date of Birth: Date Format: MM slash DD slash YYYY Social Security Number:Patient Information is Needed for:Continuing Medical CareInsuranceLegal PuposesMilitaryPersonal UseSchoolSocial Security / DisabilityOtherOther Purpose for Patient Information:Date(s) of Treatment:*Information to be Released or Accessed: Behavior Consultation Report Discharge / Death Summary Discharge Instructions Emergency Room Record Face Sheet History & Physical Lab / Pathology Reports Operative Reports Radiology Images Radiology Reports Other Other Information to be Released or Accessed:Format Requested for Information to be Provided: Electronic Media (requires 2 business days) Paper Fax to HealthCare Office Method of Delivery:* Mail (please provide address below) Pickup (you will be notified via a telephone call when your records are ready) Name of Individual Receiving Records: First Last Phone NumberHospital / Healthcare Facility Name:(May release the above information to)Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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: Signature:*Patient or Legally Authorized RepresentativePhoto ID:Please upload a copy of your photo ID.CommentsThis field is for validation purposes and should be left unchanged.