NEW - Authorization for Use and Disclosure of Health Information and Patient Access

Gryphon Healthcare

4700 W. Sam Houston Parkway N. Ste. 140

Houston, TX 77041


For Any Questions Please Contact:

Email: MedRecs@gryphonhc.com

Phone: (832) 653-3200

Fax: (832) 653-2978


Types of Requests:

Attorney: Medical/Billing records requests from an attorney's office or a retrieval company.

Attorney - LOP: Medical/Billing records requests accompanied by a Letter of Protection.

Attorney - Worker's Comp: Medical/Billing records requests from an attorney's office representing a patient with a worker's compensation case.

BULK: Insurance or retrieval company, on behalf of an insurance company, requesting records for multiple patients in a single attachment. (drop down arrow will provide a list of company names)

Disability: Medical and/or billing requests for disability purposes. (i.e. Social Security Administration)

Government: Requests from government officials or on behalf of a government official. (i.e. Department of Veterans Affairs, Office of Injured Employee Counsel, Child Protection Services)

Health Department: Requests from a government health official. (i.e. County Public Health)

Insurance: Requests from insurance companies and/or retrieval companies on behalf of insurance companies with a single patient on each request. (i.e. Anthem Blue Cross Blue Shield, United Health Care, eNoah, Parameds, etc.)

Patient Personal: Patient or parent of patient requesting records.

Physician - STAT: Requests from medical facilities and physicians.

 
 
 
 
 

MM/DD/YYYY

 
mm/dd/yyyy
 
 

First and Last

 
 
Phone
 
Phone
 
 
 
 
 
 

(MM/DD/YY to MM/DD/YY) or (MM/DD/YY to Present)

 
 

Select all that apply:

 
 

Qualified personal representatives (example: guardianship of patient, executor of estate, power of attorney, death certificate) must submit supporting documentation to: MedRecs@gryphonhc.com

 
 

Please note: Records for personal use can only be picked up from a facility or mailed to the address or email on file.

Please include: Recipient's Name or Organization (if applicable), Mailing Address, Email, Phone Number, or Fax Number of the recipient.

 
 
 

I UNDERSTAND: X This authorization is valid for 180 days unless otherwise stated. X A photo copy or fax of this authorization is as valid as the original. X I may revoke this authorization at any time by submitting a revocation in writing to Gryphon Healthcare. X If I revoke this authorization, the revocation will not apply to information already released in good faith before the revocation was received. X Treatment may not be conditioned on my completion of this authorization form. X If the recipient identified above is not covered by Federal or Texas privacy laws, the information may not be protected under these laws once it is disclosed to the recipient and, may be subject to re-disclosure by the recipient. X I may be asked to provide proof of my identity/guardianship with this authorization. X Fees/charges will comply with all laws and regulations applicable to release protected health information. Payment is due at time of release of information.

 
 
Drop your files here
 
 

Quality Assurance: Verifying and Uploading Information

Please carefully review and verify the entered information, including the date of birth, patient name, uploaded HIPAA document, any affidavits, LOP, etc.


Note: Delays may occur if the information provided is incomplete or inaccurate, requiring the submission of a new request at a later date.

 
 
  • Review all information entered is accurate, including the date of birth, patient name, affidavits, HIPAA documents, etc.


  • Check the box upon completion