8301 Katy Freeway | Ste 101 | Houston, Texas
Scheduling Direct Line: (713)489-1741
I have been provided access to Texas Regional Clinic Notice of Privacy Practices. I understand that I am entitled to a copy of these practices at my request.
I furthermore acknowledge that I have the right to designate access to my Protected Health Information (PHI) to anyone of my choosing. I hereby authorize disclosure of my PHI to the following individual(s).
I request the following restrictions to releasing my PHI:
I understand I may revoke this authorization at any time by submitting a written request to Texas Regional Clinic Privacy Officer, as per the office’s Notice of Privacy Practices.
I understand that by signing this authorization, this information will be used by Texas Regional Clinic to make determinations for the release of my PHI. I also understand this authorization will remain in effect until I request an update and/or amendment.