1604 Hospital Parkway, Suites 507 and 508, Bedford, TX 76022 | Call us Today: (817) 354-7268

Patient Release Form

    CATHAL P. GRANT, MD, PA

    1604 HOSTPITAL PARKWAY, SUITE 507

    BEDFORD, TX 76022

    Phone# 817.354.7268  Fax# 817.354.9930

     

    Every new patient must complete and submit this form prior to scheduling an appointment with The Grant Group. Existing patients will need to complete and submit every three years, upon request by The Grant Group staff.

    AUTHORIZATION FOR DISCLOSURE OF
    PROTECTED HEALTH INFORMATION



    I, authorize Cathal P. Grant, MD, PA, and/or the staff of Cathal P. Grant, MD, PA, to:

    Disclose Protected Health Information to:

    Obtain Protected Health Information from:



    The Protected Health Information to be disclosed is:

    MY ENTIRE RECORD     OR

    ONLY the following information:

    Psychiatric Evaluation

    Hospital Reports

    Progress Notes

    (H & P and/or Discharge Summary)

    Therapy Notes

    Treatment Plan

    Diagnosis/Assessment

    Billing Records

    Alcohol/Drug Abuse Treatment

    Estimated Length of Treatment

    Other(specify)

    The Protected Health Information is being used or disclosed for the following purposes (or "at the request of the individual"):

    Medical Care

    Case Management (including reimbursement determination and processing of benefit claims)

    Determination of Employment Status (including disability leave)

    Other (specify):

    The information may include information on HIV, AIDS, alcohol use, drugs and mental health.

    The authorization shall be in force and effect until I revoke it, at which time this authorization to use or disclose the protected health information expires. I understand that I have the right to revoke this authorization in writing at any time by sending such written notification to the practice's Privacy Contact at 1604 Hospital Pkwy, Suite 507, Bedford, TX 76022. A revocation is not effective to the extent that Cathal P. Grant, MD, PA, has relied on the use or disclosure of the Protected Health Information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

    I understand information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

    Cathal P. Grant, MD, PA, will not condition my treatment payment enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization
    for the requested use or disclosed except (1) if my treatment is related to research or (2) health care services are provided to me solely for the purpose of creating
    Protected Health Information for disclosures to a third party.

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.









     

     

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