8301 Katy Freeway | Ste 101 | Houston, Texas
Scheduling Direct Line: (713)489-1741
Completion of this document authorizes the disclosure and/or use of health information about you. The purpose is to give your health care provider permission to leave certain health information on your phone messaging service. Failure to provide all information requested may invalidate this authorization.
I hereby authorize Texas Regional Clinic and their staff to be able to call telephone number:
and leave a detailed message/voicemail with the following information:
Purpose of requested use or disclosure:
This authorization expires 90 days from today's date:
I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits.
If the health information is being disclosed or used, I may inspect or obtain a copy of this health information.
I may revoke this authorization at any time, but I must do so in writing and submit it to the following address:
My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization. I have a right to receive a copy of this authorization.
Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such redisclosure is in some cases not protected by state law and may no longer be protected by federal confidentiality law (the Health Insurance Portability and Accountability Act of 1996, also known as HIPAA).
If any of the HIPAA-recognized exceptions to this statement apply, then this statement must be changed to describe the consequences to the individual of a refusal to sign the authorization when that covered entity can condition treatment, health plan enrollment, or benefit eligibility on the failure to obtain such authorization. A covered entity is permitted to condition treatment, health plan enrollment, or benefit eligibility on the provision of an authorization as follows: (i) to conduct research-related treatment, (ii) to obtain information in connection with a health plan’s eligibility or enrollment determinations relating to the individual or for its underwriting or risk rating determinations, or (iii) to create health information to provide to a third party or for disclosure of the health information to such third party. Under no circumstances, however, may an individual be required to authorize the disclosure of psychotherapy notes. 2 Under HIPAA, the individual must be provided with a copy of the authorization when it has been requested by a covered entity for its own uses and disclosures.