PHI Disclosure Authorization | Texas Sleep Docs

Texas Sleep Docs PHI Disclosure

Kathy Wilson, M.D. | David Duhon, M.D., J.D.

Authorization to Disclose Protected Health Information

Prohibition of redisclosure: This information has been disclosed to you from records, which are confidential. You are prohibited from making any further disclosure of it without the specific written consent of the patient, or as otherwise permitted by law.

Patient Name*

First Last

Date of Birth*

I hereby authorize Texas Sleep Docs to release and/or obtain the following protected health information:

Prior Consultations
Sleep Study Reports
X-Ray Reports/Imaging
Lab/Pathology Reports
Emergency Room Records
Operative Reports

For the purpose of CONTINUITY OF CARE.

Healthcare Providers (Previous and Current)*

Agreement/E-Signature Disclaimer - I understand the specific information to be released may include, but is not limited to: history, diagnosis and/or treatment of drug or alcohol abuse, mental illness, or communicable disease including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). I authorize the release of this specific data. I also understand this authorization may be revoked by the person giving authorization by a written and dated notice, except to the extent that disclosure of information has been made prior to receipt of the revocation. This authorization will be in force for one year after I sign it. I have read and understand this consent, and I have signed it voluntarily. By selecting the "I agree" checkbox, you agree to the following: You are 18 years of age or older. You acknowledge the risk of sending information by email and will not hold Texas Sleep Docs liable for any damages you may incur as a result of the transfer or use of this information.*

Agreed - Electronically Signed

Patient or Authorized Agent*

First Last