This authorization may be used to permit a covered entity (as such term is defined by HIPAA and applicable Texas law) to use or disclose an individual's protected health information. Individuals completing this form should read the form in its entirety before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their protected health information.
*Information regarding patient for whom authorization is made:
 
 
 
 
 
 
 
 
 
 
*Information regarding health care provider or health care entity authorized to disclose this information:
 
 
 
 
 
 
*Information regarding person or entity who can receive and use this information:
 
 
 
 
 
 
Specific information to be disclosed:
 
From:
 
 
to:
 
 
 
 
Include: (Indicate by Initialing)
 
 
Drug, Alcohol or Substance Abuse Records
 
 
Mental Health Records (Except Psychotherapy Notes)
 
 
HIV/AIDS-Related Information (Including HIV/AIDS Test Results)
 
 
Genetic Information (Including Genetic Test Results)
Reason for release of information:
(Choose all that Apply)
 
 
 
 
 
 
 
 
 
 

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
 
Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 958
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.