TEXAS DEPARTMENT OF CRIMINAL JUSTICE - HEALTH SERVICES DIVISION - AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

Sep 17, 2026

Authorization form for use and disclosure of protected health information (PHI) by the Texas Department of Criminal Justice, Health Services Division. Captures patient identifiers and authorization details, including the specific person or organization receiving PHI. Specifies that any and all information from the offender health record (all formats) may be disclosed for inquiries about the offender’s health and/or access to health care. Explains included sensitive categories, expiration after 180 days, revocation and re-disclosure risks, and the voluntary nature of signing.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Authorization Details

Patient Information and Recipient

Authorized PHI and Purpose

Sensitive Information, Expiration, and Rights

# TEXAS DEPARTMENT OF CRIMINAL JUSTICEHEALTH SERVICES DIVISION AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION(PHI) Patient Name(print): TDCJ-CID\#: Date of Birth: | Social Security Number: | | --- | | | By signing this Authorization Form,I understand that I am giving my authorization to TDCJ's designated medical recordscustodians to use and/or disclose my protected health information(PHI),as described in more detail in the paragraphsbelow,to the following person(s)or organization(s): | Name of person(s)or organization(s): | | --- | | Street address: | | City,State,and zip code: | | Telephone number: | | Facsimile number: | I specifically authorize the use and disclosure of the following PHI:(Please provide a detailed description of the particular information you are authorizing to be disclosed) | ANY AND ALL INFORMATION FROM THE OFFENDER HEALTH RECORD(ALL FORMATS). | | --- | If this authorization is for any purpose other than the release of medical records for personal reasons,please state thepurpose of the authorization to release PHI below: | RESPONDING TO AN INOUIRY REGARDING THE OFFENDER'S HEALTH AND/OR ACCESS TO HEALTH CARE. | | --- | The information to be used or disclosed pursuant to this authorization form may include information relating to:(1)Acquired immunodeficiency syndrome(AIDS)or human immunodeficiency virus("HIV")infection;(2)treatment for drugor alcohol abuse;or(3)mental or behavioral health or psychiatric care. Unless earlier revoked,this authorization will expire on the 180ᵗday of the signing or as otherwise specified below: I understand the information disclosed pursuant to this authorization may be re-disclosed by the recipient and may nolonger be protected by federal or Texas privacy law. I may inspect and receive a copy(Texas law establishes nominal fees for copy charges of medical records)of theinformation to be used and disclosed pursuant to this Authorization Form. This Authorization is voluntary and I may refuse to sign this Authorization Form. If I am providing authorization for marketing purposes,I understand that TDCJ may receive remuneration from a properlyauthorized business associate as a result of using or disclosing my PHI. I understand that I am not required to sign this Authorization form in exchange for receiving treatment from TDCJ. Signature of patient or personal representativeDatePrinted name of patient Printed name of personal representative(if applicable) Relationship of personal representative to the patient (if applicable)HSA-27(6/03)

FAQs

Who may use or disclose the protected health information (PHI) under this form?

The form authorizes TDCJ’s designated medical records custodians to use and/or disclose the patient’s PHI.

What PHI does the authorization cover and for what purpose?

It authorizes disclosure of any and all information from the offender health record (all formats) for responding to an inquiry regarding the offender’s health and/or access to health care.

When does the authorization expire and what are the key patient rights?

Unless earlier revoked, the authorization expires on the 180th day after signing. The recipient may re-disclose the information and it may no longer be protected by federal or Texas privacy law; the patient may inspect and receive a copy and may refuse to sign.

Sep 17, 2026

Upload by Riley West