Texas Physician Health Program (TXPHP)

Authorization and Consent to Release Information

TO TXPHP FROM TXPHP

Name __ Address ______City, State, Zip

Date of Birth __

TO TXPHP / I hereby authorize and request that the physician(s), hospital(s), treatment centers or other healthcare provider(s) listed below release to the Texas Physician Health Program the following information for purposes related to recovery:
Records from the following facility/provider: Address: City, State, Zip:
Types of Records to be Released: Assessment/Evaluation Findings Discharge Summary Alcohol Screening Reports Psychiatric/Psychological Records Drug Screen Reports Other (Specify)
I hereby authorize the release of the above information and release and hold harmless the physician(s), hospital(s), treatment centers or other healthcare provider(s), their members, agents or employees from any and all claims for damages arising out of or related to the release of the information specified above. I understand that this authorization is voluntary. I also understand that the TXPHP to whom this information is sent may re-disclose the information to its agents, employees and others serving within the TXPHP.
  1. I understand that the source(s) named above will be told that the information they give will remain confidential. I hereby waive my right of access to any information obtained from these sources.
  2. I understand that I have the right to withdraw this authorization at any time and that thisauthorization shall expire, without my written revocation, five (5) years from the date of my signature. I authorize a photocopy of this release to be used in lieu of an original signed document.
  3. The information contained herein is confidential and is being provided in response to this written authorization.
Date ______
Consenting Party’s Signature
FROM TXPHP / I hereby authorize and request that the TXPHP release the following information which may be available:
Drug Screen Report Compliance/Advocacy Other (Specify)
Release the documents to the following recipient: Name of facility or individual: Title
Address: City, State, Zip:
I authorize TXPHP to release the information via email to this address:
I authorize the release of the above information and hold harmless the TXPHP, its members, agents or employees from any and all claims for damages arising out of or related to the requested release.
1)I understand this information is being released for the following purpose(s):
2)I understand that I have the right to withdraw this authorization at any time and that thisauthorization shall expire, without my written revocation, five (5) years from the date of my signature. I authorize a photocopy of this release to be used in lieu of an original signed document.
3)Statement of Confidentiality. “The information obtained herein has been disclosed to you from records whose confidentiality is protected by State and Federal law. State and Federal law prohibits you from making any further disclosures of the information without the specific written authorization of the person to whom it pertains, or except as otherwise permitted by law. A general authorization for the release of medical or other information is NOT sufficient for this purpose”.
This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosures of this information unless such disclosure is expressly permitted by the written consent of the person who it pertains to or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse person.
Date ______
Consenting Party’s Signature

DISCLAIMER: TXPHP is NOT a healthcare provider & will sign a HIPAA Business Associate Agreement if requested to do so.

333 Guadalupe, Suite 2-520 Austin, TX 78701Phone: (512) 305-7462Fax: (512) 463-0216