Registration-HIPAA Authorization and Notice of Receipt of Privacy Practices

    • Texas Regional Clinic


      www.TexasRegionalClinic.com

      8301 Katy Freeway | Ste 101 | Houston, Texas



      Scheduling Direct Line: (713)489-1741

      Fax: (713)984-8481

      Email: FrontDesk@TexasRegionalClinic.com


      HIPAA Authorization and Notice of Receipt of Privacy Practices

    • Date Format: MM slash DD slash YYYY

    • 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.


    • Date Format: MM slash DD slash YYYY
      (Today's Date)
    • Your Signature (Type Your Name)

  • This field is for validation purposes and should be left unchanged.