AUTHORIZATION FOR EXCHANGE/RELEASE OF INFORMATION

Please 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.

I do hereby consent to the exchange and/or disclosure of information regarding the evaluation and treatment of the above named person and acknowledge that I have the legal right to grant this authorization for release of information.

By and between Mind Works, located at: 

17115 San Pedro Ave Ste 370 San Antonio TX 78232