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Authorization to Disclose Protected Health Information

Texas Health & Safety Code § 181.154(d)

Authorization to Disclose
Protected Health Information

Developed for Texas Health & Safety Code § 181.154(d)

Effective June 2013

Gruene Lake Medical

948 Gruene Road, #140, New Braunfels, TX 78130 | 830-627-2700

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information.

Covered entities as that term is defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed authorization from the individual or the individual's legally authorized representative to electronically disclose that individual's protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law.

Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.

NAME OF PATIENT OR INDIVIDUAL

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Enter "NA" if not applicable
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Enter "None" if not applicable
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Enter "NA" if not applicable
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I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION

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Enter "NA" if not applicable
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WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

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Enter "NA" if not applicable
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REASON FOR DISCLOSURE (Choose only one option)

Enter "NA" if one of the above options was selected
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WHAT INFORMATION CAN BE DISCLOSED?

Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.

Enter "None" if not applicable
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Your initials are required to release the following sensitive information:

Enter "NA" for initials if you do not wish to authorize release of that specific category

EFFECTIVE TIME PERIOD

This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or the following specific date:

If left blank, authorization remains valid until withdrawn or death

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under "WHO CAN RECEIVE AND USE THE HEALTH INFORMATION." I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

SIGNATURE AUTHORIZATION

⚠️ Electronic Signature Notice: By typing your full name below, you are creating a legally binding electronic signature that has the same legal effect as a handwritten signature.
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Enter "Self" if signing for yourself
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Enter "NA" if Self or one of the above options was selected
Please select a relationship or specify

Note: A minor individual's signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, e.g., Tex. Fam. Code § 32.003).

⚠️ Electronic Signature Notice: By typing your full name below, you are creating a legally binding electronic signature that has the same legal effect as a handwritten signature.
Enter "NA" if not applicable
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Your authorization has been submitted successfully.

A copy has been sent to your email address.

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Important Notice

Gruene Lake Medical is currently only accepting new baby patients.

If you are filling out this form for a patient other than a new baby (infant), please be aware that we may not be able to accept this patient at this time.

By clicking "I Understand" below, you acknowledge this limitation and wish to proceed with the form submission.