HIPAA Acknowledgement
I authorize the disclosure of my protected health information* as described herein. I understand that this authorization is voluntary and made to confirm my direction. I understand that if the person(s) or organization(s) that I authorize to receive my protected health information are not subject to federal and state health information privacy laws**, subsequent disclosure by such person(s) or organization(s) may not be protected by those laws.
1. I authorize the following person(s) and/or organization(s) to disclose my protected health information:
All healthcare providers who have provided healthcare to me.
2. I authorize the following person(s) and/or organizations to receive my protected health information as disclosed by the person(s) and/or organization(s) above.
Wichita Falls ISD-Department of Risk Management Claims Administrative Services, Inc.
P.O. Box 97533 P.O. Box 7500
Wichita Falls, Texas 76307 Tyler, Texas 75711
Texas Department of Insurance Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100
Austin, Texas 78744-1609
3. Specific description of the protected health information that I authorize for disclosure: Any and all records regarding my health, including medical histories, consultations, examinations, prescriptions, diagnosis, tests, reports or treatments. I further specifically authorize the disclosure of psychotherapy notes, if any.
4. The purpose for requesting this information is for use by the carrier to evaluate, adjust, describe, or report matters about my health to persons entitled to receive this information.
5. I understand that I may revoke this authorization in writing at any time, except to the extent that the person(s) and/or organization(s) named above have taken action in reliance on this authorization.
6. I understand that treatment and payment for my treatment are not conditioned on my agreement to this authorization. *Protected health information (“PHI”) is health information that is created or received by a health care provider, health plan, or health care clearinghouse which relates to 1) the past, present or future physical or mental health of an individual; 2) the provision of health care to an individual; or 3) the past, present, or future payment for the provision of health care to an individual. To be protected, the information must be such that it identifies the individual or provides a reasonable basis to believe that the information can identify the individual. 45 C.F.R. 164.508 **These laws apply to health plans, health care providers, and health care clearinghouses.
7. I understand that the release of protected health information to a non-covered entity may invalidate its protection.
8. I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug and/or alcohol use. If I have been tested, diagnosed or treated for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug and/or alcohol use, you are specifically authorized to release all healthcare information related to such diagnosis, testing or treatment.
9. This authorization expires on two years from the date of authorization, or the date that my workers’ compensation claim is finally closed, whichever occurs first.
By entering your name in the below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
I have had the opportunity to read and consider the contents of this authorization. I confirm that this authorization is a true and correct statement of my intention to permit the disclosure of my PHI as described in this authorization.
Pursuant to the Texas Uniform Electronic Transmissions Act, an electronic signature has the same legal effect as a manual or handwritten signature. An electronic signature will not be denied legal effect or enforceability solely because it is electronic, and any requirement for a signature is satisfied by an electronic signature. By submitting an electronic signature, the individual identified and providing the electronic signature herein verifies acknowledgement of the binding legal effect and enforceability of the electronic signature. By clicking the box beside "I agree", you agree that this is valid as your signature. You hereby swear that you are the above named employee and that the information is accurate to the best of your knowledge.
