SUSAN D. GIFFORD, Ph.D. P.C. & ASSOCIATES

3508 Hwy 121 Bedford, TX  76021 817.858.6745 Fax 866.341.1114 www.DrGifford.com

 

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

Patient:

_________________________________________

_________________________________________

Name of Patient/Previous Names

Birth Date/Medical Record Number

_________________________________________

_________________________________________

Street Address

City, State, Zip


Authorizes:


Release Of Protected Health Information To/From:

_________________________________________

Susan D. Gifford, Ph.D., FPPR, FICPP or designated office staff

Name of Physician/Pediatrician/Other

Name of Health Care Provider/Other

_________________________________________

3508 Highway 121                                 

Street Address

Street Address

_________________________________________

Bedford, TX 76021                                                                  

City, State, Zip

City, State, Zip

_________________________________________

 

Phone Number

 


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:  _________________________________