AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
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: