This completed form authorizes a third party to disclose a patient’s protected health information to Texas Children’s Pediatrics. Authorization for Disclosure of Protected Health Information Patient Contact Information Name of Patient ____________________________________________ Date of Birth _________________________________________________ Address (City, State, ZIP) _____________________________________ Phone ______________________________________________________ __________________________________________________________ Dates of Service ____________________________________________ Reports to be Disclosed History and Physical Exam Consultation Reports Progress Notes Radiology Reports Laboratory Reports Pathology Reports Immunization Record _____ _____ _____ _____ _____ _____ Please indicate those reports that you would like to be disclosed. Growth Chart _____ Operative Reports _____ Billing Claims Forms _____ Itemized Statement of Charges _____ All Information _____ Other _____________________________________________________ _____________________________________________________ Records Released From Name ____________________________________________________ Phone ______________________________________________________ Mailing Address ____________________________________________ Fax ________________________________________________________ City, State, ZIP _____________________________________________ Records Released To Name ____________________________________________________ Phone ______________________________________________________ Mailing Address ____________________________________________ Fax ________________________________________________________ City, State, ZIP _____________________________________________ Reason for record release _____________________________________ __________________________________________________________ Authorization I authorize the third party named in the above section to disclose the protected health information about myself (or the patient) as described above. I understand: This authorization expires 180 days from the date of my signature unless I specify otherwise. Expiration _________________________________________________________________ I may revoke this authorization at any time by notifying Texas Children’s Pediatrics in writing. If I revoke the authorization, I understand that it will have no affect on actions Texas Children’s Pediatrics took in good faith before receiving the revocation. The information released may contain information related to AIDS or HIV infection; drug or alcohol abuse; mental or behavioral health or psychiatric care, except for psychotherapy notes. Texas Children’s Pediatrics may not condition treatment or payment on my completion of this form. Texas Children’s Pediatrics reserves the right to verify my identity or guardianship. Signature _________________________________________________________________ Date ________________________________ Printed Name ______________________________________________________________ Relationship to Patient _______________________________________________________ Thank you for choosing Texas Children’s Pediatrics Form 10 – September 2012