Release of Information Form

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

Name *

First

Last

Date of Birth *

Social Security # *

Policy Number (Primary): *

TPACS is authorized to *

disclose to
and/or obtain from

Name *

Phone *

Please enter a valid phone number.

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Relationship *

Check all that apply *

If Other was selected above (specify)

For the following purpose: Check all that apply *

If Other was selected above (specify)

Send family program packet and questionnaire (where applicable)

I understand these records may contain information concerning sexually transmitted disease(s), acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), drug abuse, substance abuse, alcoholism, sickle cell anemia, and behavior or mental health services.

I understand that this authorization, except for action already taken, may be revoked by me at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to TPACS. Unless otherwise revoked, this authorization will expire one year from today’s date and must postdate any date of service being requested

This authorization becomes null and void from the date entered in the chart that the chart will be closed.

I understand that TPACS will not condition treatment, payment, enrollment, or eligibility for benefits concerning my health care on whether I sign or refuse to sign this authorization.

I understand that authorizing the disclosure of this health information is voluntary and that disclosure of such information carries with it the potential for unauthorized re-disclosure.

Todays Date: *

Date