Authorization

AUTHORIZATION FOR RELEASE OF
PROTECTED HEALTH INFORMATION

Patient’s Name: ____________________________________________________________________________
Last
First
Middle
Maiden
Date of Birth: ____/_____/______

Contact Number: _________________________

1. I hereby authorize
Any and all Harris County Hospital District Community Health Centers
Any and all Houston Department of Health and Human Services Health Centers
Any and all Legacy Community Health Services Clinics
________________________________________________________________________
(Name of Physician/Clinic/Hospital/Institution, etc.)
________________________________________________________________________
(Name of Physician/Clinic/Hospital/Institution, etc.)
________________________________________________________________________
(Name of Physician/Clinic/Hospital/Institution, etc.)
________________________________________________________________________
(Name of Physician/Clinic/Hospital/Institution, etc.)
to release copies of all labs and related reports of the above named patient for the time period
______________________ to present.
2. This information shall be released to: Houston Department of Health and Human Services, Bureau of
Epidemiology, 8000 N. Stadium Drive, Houston, Texas, 77054.
3. The Purpose of Disclosure is at the request of the above named patient as a participant in the research
study, “Assessing the Accuracy of Self-Reported HIV Testing Behavior,” approved by the Committee for
the Protection of Human Subjects of the University of Texas Health Science Center at Houston
(HSC-___-___-___).
4. I understand that this request can be cancelled in writing. HDHHS, the above named facilities, and their
employees will not be liable for releases made before I cancel this request.
5. I understand that when the information is released based on this request; it may be subject to re-release by
the recipient and may no longer be protected health information.
6. I understand that the medical information indicated above may contain extremely confidential information
including Human Immunodeficiency Virus (HIV) and other sexually transmitted diseases (STD) test
results.
7. I understand that this release is valid until the conclusion of the research study. I can indicate an earlier
expiration date here: _______________________.
_________________
Date

______________________________________
Signature of Patient

__________________________
Relationship if not Patient