I authorize PrimCare to disclose the above name individual’s private health information. This information may be disclosed TO and used by the following individual or organization:

*Please release the following:

I understand that the information in my health record may include information related to sexually transmitted disease, acquired immunodeficency syndrome (AIDS), or human immunodeficency virus (HIV). It may include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

If no expiration is selected, the authorization will automatically expire 180 days from the date of signature, as permitted by Texas law.

I have the right to revoke this authorization at any time by submitting a written notice to PCEC. If I revoke, PCEC will stop using or disclosing my PHI after the revocation date, except for actions already taken in reliance on this authorization.

I understand that once my health information is disclosed to the recipient listed above under this authorization, that recipient may redisclose my information, and that it may no longer be protected by federal or Texas privacy laws. If I revoke, PCEC will stop using or disclosing my PHI after the revocation date, except for actions already taken in reliance on this authorization.

Fee charged for reproduction of records: $25 (pages 1-20), $0.15 per page thereafter

Cost of Affidavits/Notary (If needed): $15 per signed page

Postage costs if applicable