Release of information

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.

Shea T. Sawyer, PMHNP-BC,
Board Certified Nurse Practitioner
SawyerNP.COM
Tel: +1 (281) 801-8090
Fax: +1 (281)-503-5903

WHAT INFORMATION CAN BE DISCLOSED? Complete the following by indicating those items that you want disclosed. The signature of a parent or legal guardian is required for a minor patient under the age of 18 years old.