SUSAN D. GIFFORD, Ph.D. P.C. & ASSOCIATES
Office: 6215 Colleyville Blvd – Mailing Address: 1420 Douglas Ave. ● Colleyville, TX 76034 ● 817.858.6745 ● Fax 866.341.1114 ● www.DrGifford.com
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AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
Information To Be
Released:
___ Medical History, Examination, Reports ___ Entire Record ___ Immunizations
___ Therapy/Progress Notes ___ Hospital Records Including Reports ___ X-ray Reports
___ Evaluation ___ Laboratory Reports ___ Prescriptions
___ Consultations ___ Surgical Reports ___ Allergy Records
___ Other (Specify):
Purpose For Need Of
Disclosure: (Check applicable
categories)
___ Further Medical Care ___ Legal Investigation or Action ___ Personal
___ Insurance Eligibility/Benefits ___ Changing Physicians
___ Other (Specify): ______________________________________________________________________________
I
understand that if the person(s) and/or organization(s) listed above are not
health care providers, health plans or health care clearinghouses, who must
follow the federal privacy standards, the health information disclosed as a
result of this authorization may no longer be protected by the federal privacy
standards and my health information may be redisclosed without obtaining my
authorization.
Your Rights With
Respect To This Authorization:
Right to Inspect or Copy the Health Information to Be Used or Disclosed
- I
understand that I have the right to inspect or copy the health information I
have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health
information or obtain copies of my health information by contacting Dr. Susan
Gifford’s office staff. Right to Receive Copy of This Authorization
- I understand that if I agree to sign this authorization, which I am not
required to do, I must be provided with a signed copy of the form. Right
to Refuse to Sign This Authorization - I understand that I am under no
obligation to sign this form and that the person(s) and/or organization(s)
listed above who I am authorizing to use and/or disclose my information may not
condition treatment, payment, enrollment in a health plan or eligibility for
health care benefits on my decision to sign this authorization. Right
to Withdraw This Authorization - I understand written notification is necessary
to cancel this authorization. To obtain
information on how to withdraw my authorization or to receive a copy of my
withdrawal, I may contact Dr. Susan Gifford’s office staff. I am aware that my withdrawal will not be
effective as to uses and/or disclosures of my health information that the
person(s) and or organization(s) listed above have already made in reference to
this authorization.
Expiration Date: This authorization is good
until the following date(s) or
for one year from the date signed.
I have had an opportunity to review and understand the
content of this authorization form. By
signing this authorization, I am confirming that it accurately reflects my
wishes.
Signature Of Patient
or Legal Representative: _________________________________Date:
(If signed by
other than patient, state relationship and authority to do so.)
Witness: _________________________________ |