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The requester provides patient identifiers and contact details, selects disclosure options (verbal disclosure to non-providers or records release to medical/mental health providers), and specifies what will be released, including counseling, psychiatric, laboratory, and treatment summary categories. The form explains validity while the signer is a UT Austin student, revocation steps, potential inclusion of sensitive health topics such as HIV/AIDS, and submission requirements to CMHC.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-for-release-of-protected-health-information-phi/288407/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-for-release-of-protected-health-information-phi/288407.png","ImageObject",442,249,{"name":88,"@type":89},"Alex Sinclair","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who can the protected health information be released to?","Question",{"text":108,"@type":109},"The PHI can be released via verbal disclosure to a non-provider (such as family or friends) or as records released to a medical or mental health provider, as selected in the form.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How long is this authorization valid?",{"text":113,"@type":109},"It is valid as long as the signer is a UT Austin student unless they notify CMHC otherwise.",{"name":115,"@type":106,"acceptedAnswer":116},"How can the authorization be revoked?",{"text":117,"@type":109},"Revocation can be made in writing at any time, by completing a CMHC Request to Amend Record Form and stating the intention to revoke, then submitting it to CMHC Records.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288407,1790006292,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1099523882182,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Authorization for Release of   \nProtected Health Information (PHI)  \nI authorize the following protected mental health information to be released from the medical record of:  \nlast name (please print)  \nfirst name (please print)  \nknown by  \nemail address uteid date of birth today’s date  \n\n| p Verbal disclosure to a non-provider\u003Cbr>(e.g., family, friend, SES, faculty, staff):    \u003Cbr>name/relationship phone number\u003Cbr>To be released: p Conversations as needed to facilitate continuity of care\u003Cbr>p Other   |  |  |  |\n| --- | --- | --- | --- |\n| p Records release to Medical or Mental Health Provider: |  |  |  |\n| Release PHI\u003Cbr>p From\u003Cbr>p To | Counseling and Mental Health Center 100 A West Dean Keeton, A3500 Austin, TX 78712\u003Cbr>Phone 512-471-3515\u003Cbr>Fax 512-232-7314 | Release PHI\u003Cbr>p To\u003Cbr>p From | name/organization/provider role address city state zip code\u003Cbr>phone fax |\n| I understand that to the extent that any recipient of this information, as identified above, is not a “covered entity” under Federal or Texas privacy law, the information 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.\u003Cbr>TO BE RELEASED DATE OF SERVICE / PROVIDER TO BE RELEASED\u003Cbr>p Counseling records   p Conversations as needed to\u003Cbr>p Psychiatric records   facilitate continuity of care\u003Cbr>p Laboratory results   p Date of appointments\u003Cbr>p Treatment summary   p Other, as specified below\u003Cbr>p Other: \u003Cbr>a NOTE: If specific dates to be released or a specific provider are not indicated, all records in the category marked will be released. |  |  |  |\n\nI understand that this authorization is valid for as long as I am a UT Austin student unless I notify CMHC otherwise. I may revoke this authorization in writing at any time except to the extent that CMHC has already relied on this authorization. I may revoke it by completing a CMHC Request to Amend Record Form and stating my intention to revoke this authorization. This form must be submitted to CMHC Records at the address/fax number above. I understand that the records released may include information relating to Human Immunodeficiency Virus (“HIV”) infection or Acquired Immunodeficiency Syndrome (“AIDS”); treatment for or history of drug or alcohol abuse; or mental or behavioral health or psychiatric care. If I do not want some of this information released, I must review this request with CMHC Administrative staff. I understand my treatment will not be conditioned by my completion of this form. I will be billed per the posted fee schedule. The information will be provided to me within 15 days of my request.  \na NOTE: If mailing or faxing this form, please include a copy of your photo ID.  \n\n| signature of client/patient (or if legal representative-state authority to act)\u003Cbr>I have verified the client’s/patient’s identification and notified them of the fee, if applicable. | date |\n| --- | --- |\n\ncmhc staff/trainee signature date  \n\n| CMHC STAFF ONLY | Date Released:   Released by:  \u003Cbr>Notes: |\n| --- | --- |\n\nFORM-CMHC ROI. indd-11072019","cbCainG1CvpxC3Gk","https://ap.wps.com/l/cbCainG1CvpxC3Gk","pdf",94704,"English","# Patient and Release Details\n## What Information Will Be Released\n## To Whom It Will Be Released\n# Acknowledgements and Validity\n## Validity While Enrolled\n## Revocation and Sensitive Information\n## Submission and Processing Timeline","[{\"question\":\"Who can the protected health information be released to?\",\"answer\":\"The PHI can be released via verbal disclosure to a non-provider (such as family or friends) or as records released to a medical or mental health provider, as selected in the form.\"},{\"question\":\"How long is this authorization valid?\",\"answer\":\"It is valid as long as the signer is a UT Austin student unless they notify CMHC otherwise.\"},{\"question\":\"How can the authorization be revoked?\",\"answer\":\"Revocation can be made in writing at any time, by completing a CMHC Request to Amend Record Form and stating the intention to revoke, then submitting it to CMHC Records.\"}]","Authorization for Release of Protected Health Information (PHI) | PDF",1789633453]