Dr. Bryce Gibbs Release of Information Form

BRYCE GIBBS, PH.D.
1717 WEST AVENUE, AUSTIN, TEXAS 78701
512-452-2929 FAX: 512-452-5656

AUTHORIZATION TO RELEASE/REQUEST PROTECTED HEALTH INFORMATION

Name of Patient

I hereby authorize Bryce Gibbs, Ph.D. to release/request my Protected Health information, including:

My Entire Medical Record

My Health Care Coverage, Including any Third Party Payor Information

Verbal Report

Laboratory

Psych Testing

Evaluations

Notes

History & Physical

Other

If other

To/From

Address

City

State

Zip

Phone

Fax

I have read this Authorization and understand what information will be used or disclosed, who may use and disclose the information, and the recipient(s) of that information. I understand that the purpose of releasing this information is for treatment, coordination of treatment, and payment purposes. I also understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned upon me signing this authorization.

I understand that when the information is used or disclosed pursuant to this Authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by state or federal privacy regulations.

I further understand that I retain the right to revoke this Authorization, except to the extent that action has been taken in reliance on this Authorization, if I inform Bryce Gibbs, Ph.D. in writing of my wish to revoke this authorization. Such revocation should be mailed to:

Bryce Gibbs, Ph.D.; 1717 West Avenue, Austin, Texas 78701

This Authorization shall expire when I am no longer receiving psychological and mental health services from Bryce Gibbs, Ph.D. I fully understand and accept the terms of this authorization.

Signature of Patient

Date

Signature of Legally Authorized Representative

Date

Relationship to Patient

Your information will be encrypted.