CMC English Medical Records Release

CONSENT FOR RELEASE OF MEDICAL RECORDS AND USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO A THIRD PARTY

(Name of Patient making Request)

hereby authorize Children's Medical Clinics of East Texas, (hereafter collectively referred to as the "Practice") to use and disclose:

My entire medical or record

Yes No

Test Results only

Yes No

Portions of my Medical Record

Yes No

If Portions of my Medical Record is answered as yes, please specify:

Date specific Portions of my Medical Record

Yes No

If "Portions of my Medical Records" is answered as yes, please input Date From.

If "Portions of my Medical Records" is answered as yes, please input Date To.

I acknowledge that this Healthcare Facility, in accordance with their Notice of Privacy Practices (NOPP) and Omnibus HIPAA Law will release my specified medical records to the party listed above. I have reviewed this Practices Notice of Privacy Practices (NOPP) and have been given an opportunity to ask questions about it, understand it, and do hereby agree to its terms. A copy of this signed, dated Consent shall be as effective as the original. I release, hold harmless and agree to indemnify this Practice, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this Consent. I specifically authorize this Practice to use and disclose verbally, by mail, fax or unencrypted email, the following types of super-confidential information as stated in the NOPP (initial where appropriate):

HIV records (including HIV test results) and sexually transmissible diseases

Alcohol and substance abuse diagnosis and treatment records

Psychotherapy records

Not Applicable

REQUIRED TO COMPLETE:

In accordance with HIPAA Omnibus Rule of 2013 and Texas HB 300 Law, I understand that I need to provide the specifics of this release request:

1.) Date of this Request:

2.) Please Release my records to:

(Name of Third Party)

3.) The Records will be obtained by:

Please allow

(Name of Third Party)

to pick up a copy of my records.

Third Party will pick up a copy of my records on or arter this date:

Yes No

If yes, please specify the date:

Send Third Party a copy of my records to this address:

Yes No

If yes, please specify the address:

4.) I acknowledge I will be charged a copying cost, made payable prior to the transfer of these records, in the amount of $

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

By Patient:

(Print name)

Date:

By Patient's Representative:

(Print name and describe authority)

Date:

OFFICE USE ONLY

Describe what alternative communications were denied.

Date:

Describe what alternative communications were accepted.

Date:

Your information will be encrypted.