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This form is provided by the Division of Student Affairs of The University of Texas at Austin to authorize the disclosure or release of one person's protected health information.
UHS
STAFF
ONLY
Date Released: Released by:
Notes
Authoriza on for Release of
Medical Records
I authorize the following protected health information to be released from the medical record of:
LAST NAME (PLEASE PRINT) FIRST NAME (PLEASE PRINT) DATE OF BIRTH
EMAIL ADDRESS UTEID TODAY’S DATE
PHONE NUMBER
TO BE RELEASED DATE OF SERVICE / PROVIDER TO BE RELEASED DATE OF SERVICE / PROVIDER
Offi ce visits and lab Immuniza ons
Gyn visits and lab Physical therapy notes
Urgent Care visits Nurse Advice Line
Lab work En re record
Radiology reports Other
NOTE: If specifi c dates to be released or a specifi c provider are not indicated, all records in the category marked will be released.
REASON FOR RELEASE OF INFORMATION
At the request of the individual.
Other (DESCRIBE REASON FOR DISCLOSURE)
I understand that this authoriza on is valid for six months unless I no fy UHS otherwise. I may revoke this authoriza on in wri ng at
any me except to the extent that UHS has already relied on this authoriza on. I may revoke it by mailing or faxing a wri en no ce
to the H.I.M. Administrator to the address/fax number above sta ng my intent to revoke this authoriza on. I understand that the re-
cords released may include informa on rela ng to Human Immunodefi ciency Virus (“HIV”) infec on or Acquired Immunodefi ciency
Syndrome (“AIDS”); treatment for or history of drug or alcohol abuse; or mental or behavioral health or psychiatric care. I understand
my treatment will not be condi oned by my comple on of this form. I will be billed per the posted fee schedule. The informa on will
be provided to me within 21 days of my request.
NOTE: If mailing or faxing this form, please include a copy of your photo ID.
SIGNATURE OF PATIENT (OR IF LEGAL REPRESENTATIVE-STATE AUTHORITY TO ACT) DATE
I have verifi ed the pa ent’s idenfi ca on and nofi ed him/her of the fee.
UHS STAFF SIGNATURE / DEPARTMENT DATE
Please mail my records Please call when my records are ready for pick-up Please fax my records
NOTE: Fee schedule available at healthyhorns.utexas.edu/records
I understand that to the extent that any recipient of this informa on, as idenfi ed above, is not a “covered en ty” under Federal or
Texas privacy law, the informa on may no longer be protected by Federal and Texas privacy law once it is disclosed to the recipient
and, therefore, may be subject to re-disclosure by the recipient.