[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288397-105":53,"doc-detail-288397-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","hipaa-authorization-to-disclose-protected-health-information-authorization-form","HIPAA Authorization to Disclose Protected Health Information - Authorization Form","","Authorization to disclose protected health information form for Texas, referencing Texas Health & Safety Code § 181.154(d) effective June 2013. Covered entities obtain a signed authorization to electronically disclose an individual’s protected health information, with disclosures not required for certain treatment, payment, health care operations, specified insurance functions, or permitted legal reasons. The form collects patient identity, recipient details, disclosure purpose, and specific categories of health information, including initial-based release for sensitive items such as mental health records, genetic information, substance abuse, and HIV/AIDS results. It specifies an effective time period, revocation rights, and signature requirements for adult and minor representatives.",{"@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/hipaa-authorization-to-disclose-protected-health-information-authorization-form/288397/",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/hipaa-authorization-to-disclose-protected-health-information-authorization-form/288397.png","ImageObject",442,249,{"name":88,"@type":89},"Sophia Brooks","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"When is a signed HIPAA authorization required for electronic disclosure?","Question",{"text":108,"@type":109},"Covered entities must obtain a signed authorization from the individual or legally authorized representative before electronically disclosing protected health information, unless the disclosure fits specific categories not requiring authorization under the form.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information can be disclosed, and how are sensitive items handled?",{"text":113,"@type":109},"The form provides checkboxes for categories such as physician’s orders, progress notes, discharge summaries, lab results, and other records. For certain sensitive information (e.g., mental health records, genetic information, substance abuse records, and HIV/AIDS test results/treatment), initials are required to release it.",{"name":115,"@type":106,"acceptedAnswer":116},"Can the authorization be revoked, and what are the effects of revocation?",{"text":117,"@type":109},"The individual can withdraw permission at any time by written notice to the named recipient. Prior actions taken in reliance on the authorization are not affected, and the form explains limits and continued protections for disclosures already permitted by law.","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},288397,1790007022,{"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":79,"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},962084925636,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION  \nDeveloped for Texas Health & Safety Code § 181.154(d) effective June 2013  \nPlease read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. Covered entities as that term is defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.  \nNAME OF PATIENT OR INDIVIDUAL  \nLast First Middle  \nOTHER NAME(S) USED   DATE OF BIRTH Month   Day   Year  ADDRESS    \n______________________________________________________________  \nCITY   STATE   ZIP  PHONE (  )  ALT. PHONE (  )  EMAIL ADDRESS (Optional):    \nI AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH INFORMATION:  \nPerson/Organization Name   Address   City   State   Zip Code   Phone (   )   Fax (   )    \nWHO CAN RECEIVE AND USE THE HEALTH INFORMATION?  \nPerson/Organization Name   Address   City   State   Zip Code   Phone (   )   Fax (   )    \nREASON FOR DISCLOSURE (Choose only one option below)  \n¨ Treatment/Continuing Medical Care  \n¨ Personal Use  \n¨ Billing or Claims  \n¨ Insurance  \n¨ Legal Purposes  \n¨ Disability Determination  \n¨ School  \n¨ Employment  \n¨ Other    \nWHAT INFORMATION CAN BE DISCLOSED? Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.  \n¨ All health information  \n¨ Physician’s Orders  \n¨ Progress Notes  \n¨ Pathology Reports  \n¨ History/Physical Exam  \n¨ Patient Allergies  \n¨ Discharge Summary  \n¨ Billing Information  \n¨ Past/Present Medications  \n¨ Operation Reports  \n¨ Diagnostic Test Reports  \n¨ Radiology Reports & Images  \n¨ Lab Results  \n¨ Consultation Reports  \n¨ EKG/Cardiology Reports  \n¨ Other   \nYour initials are required to release the following information:  \n  Mental Health Records (excluding psychotherapy notes)   Genetic Information (including Genetic Test Results)  \n  Drug, Alcohol, or Substance Abuse Records   HIV/AIDS Test Results/Treatment  \nEFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or the following specific date (optional): Month   Day   Year    \nRIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.  \nSIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181. 154(c) and/or 45 C. F. R. § 164.502(a)(1) . I understand that information disclosed pursuant to this authoriza","cbCaisVfbH3SBbSa","https://ap.wps.com/l/cbCaisVfbH3SBbSa","pdf",137341,"English","# Patient and Authorization Details\n## Patient Identity and Contact Information\n## Authorized Recipient Information\n# Purpose and Information Scope\n## Reason for Disclosure\n## What Information Can Be Disclosed\n## Initials for Sensitive Information\n# Timing, Revocation, and Signatures\n## Effective Time Period\n## Right to Revoke\n## Signature Authorization (Adult and Minor)","[{\"question\":\"When is a signed HIPAA authorization required for electronic disclosure?\",\"answer\":\"Covered entities must obtain a signed authorization from the individual or legally authorized representative before electronically disclosing protected health information, unless the disclosure fits specific categories not requiring authorization under the form.\"},{\"question\":\"What information can be disclosed, and how are sensitive items handled?\",\"answer\":\"The form provides checkboxes for categories such as physician’s orders, progress notes, discharge summaries, lab results, and other records. For certain sensitive information (e.g., mental health records, genetic information, substance abuse records, and HIV/AIDS test results/treatment), initials are required to release it.\"},{\"question\":\"Can the authorization be revoked, and what are the effects of revocation?\",\"answer\":\"The individual can withdraw permission at any time by written notice to the named recipient. Prior actions taken in reliance on the authorization are not affected, and the form explains limits and continued protections for disclosures already permitted by law.\"}]","HIPAA Authorization to Disclose Protected Health Information - Authorization Form | PDF",1789633445]