Get Authorization To Disclose Protected Health Information - Oag State Tx

This guide provides clear instructions on how to complete the Authorization To Disclose Protected Health Information form developed for compliance with Texas Health & Safety Code. Follow these steps to ensure your information is disclosed correctly and in accordance with the law.

Follow the steps to fill out the form accurately.

1. Use the ‘Get Form’ button to obtain the Authorization To Disclose Protected Health Information form and open it for editing.
2. Begin by entering the name of the patient or individual in the designated fields for last name, first name, and middle name.
3. Provide any other names that the individual has used, along with their date of birth, complete address including city, state, and zip code.
4. Include contact details by filling in the primary phone number and an alternate phone number if available. Optionally, you can add an email address.
5. In the section labeled ‘I authorize the following to disclose the individual’s protected health information,’ write the name and address of the person or organization responsible for disclosing the information.
6. Select the reason for the disclosure by checking the appropriate box among the available options.
7. Specify who can receive and use the health information by filling in their name, address, and contact details.
8. Indicate what specific information can be disclosed by checking the boxes for the desired categories; if all health information is to be released, check only the first option.
9. If applicable, provide your initials next to any sensitive information that requires special authorization such as mental health records or HIV/AIDS test results.
10. Determine the effective time period for the authorization and enter it if a specific date is needed.
11. Review the rights to revoke section, ensuring you understand that you may withdraw your permission at any time.
12. Sign and date the form in the signature authorization section, and provide the printed name of a legally authorized representative if applicable.
13. If the individual is a minor, ensure their signature is provided where indicated.
14. Finally, save any changes made to the form, and consider downloading, printing, or sharing it as necessary.

Complete your documentation online to ensure your health information is properly managed.