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  • Tx Womens Health Specialists Authorization To Disclose Health Information 2020

Get Tx Womens Health Specialists Authorization To Disclose Health Information 2020-2025

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION I hereby authorize the use or disclosure of information from the medical record of: Patient Name: Medical Record#: DOB: I authorize the following individual.

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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.

Imminent danger to self or others, in which case staff contact medical and/or police personnel. Suspicion of abuse of children, the elderly, or persons with a disability, in which case staff contact the Texas Department of Family Services.

Under the CMIA, medical information is defined as: “any individually identifiable information, in electronic or physical form, in possession of or derived from a provider of health care, health care service plan, pharmaceutical company, or contractor regarding a patient's medical history, mental or physical condition, ...

While employers may believe they need medical details from an employee, they are not entitled to certain information. Requesting general health information without any relation to job duties may be considered illegal discrimination under the ADA. An employer can't request medical information without a specific reason.

Elements: A description of the PHI. The name of the person making the authorization. The name of the person or organization who is authorized to receive the PHI. A description of the purpose for the use or disclosure. An expiration date for the authorization. The signature of the person making the authorization.

The Texas Medical Privacy Act prohibits any release of PHI for marketing purposes without consent or authorization from the individual. Civil penalties: $100 per violation/day, up to $25,000/year each violation.

The term “covered entity” includes a business associate, health care payer, governmental unit, information or computer management entity, school, health researcher, health care facility, clinic, health care provider, or person who maintains an Internet site.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232