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221 Regency Parkway Suit 105,
Mansfield Texas 76063
PH: 8008593119 FAX: 8665614066



To release to:
For the purpose of  

The following specific information from my Medical Record:

Discharge Summary X-Ray Reports X-Ray Films
History & Physical Alcohol and/or drug abuse information (See 1 below)
Occ Med Clinic Records HIV - related information (See 2 below)
ER Records Operative Report
Lab Reports Other:    Specific:
1. Confidentiality of DRUG/ALCOHOL ABUSE records are protected by Federal Regulations (42 CFR, Part 2)
2. Confidential HIV-RELATED INFORMATION is any information that is likely to identify, directly or indirectly, someone as having been tested for or actually having HIV infection. Antibodies to HIV, AIDS, or related infections or illness, or someone suspected of having HIV as a result of high risk activities. PATIENT DOES NOT HAVE TO AUTHORIZE RELEASE OF HIV-RELATED INFORMATION.

I DO NOT authorize release of HIV-related information

I understand that I may revoke this consent at any time by providing written notice of revocation to the Workforce Health System PLLC. This authorization shall expire 180 days from date it is signed, unless sooner revoked, but not retroactive to the release of information made in good faith; and further, that upon fulfillment of the above-stated purpose, this consent will automatically expire without my express revocation. I understand that my refusal to sign or revocation of this authorization will not affect the commencement, continuation, or quality of my treatment at the Workforce Health System PLLC except, however, if my treatment is for the sole purpose of creating health information for disclosure to the recipient identified in this authorization, in which case the Workforce Health System PLLC may refuse to treat me if I do not sign this authorization.

I understand that the Workforce Health System PLLC may, directly or indirectly, receive remuneration for a third party in connection with the use or disclosure of my health information.
I understand that once the Workforce Health System PLLC discloses my information to the recipient, the Workforce Health System PLLC cannot guarantee that the recipient will not disclose my health information to a third party. The third party may not be required to abide by this authorization or applicable federal and state laws governing the use and disclosure of my health information.

To the Party receiving this information: This information has been disclosed to you from the records whose confidentiality is protected by federal law. Federal regulations (42CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2 AND ALL OTHER PATIENTS.

Signed:   Date:
Relationship if signed by other than Patient:
Witness:   Date:

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