Authorization For Use and Disclosure of Health Information and Patient Access

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

Type of Request*

Select or enter value

Bulk Company*

Select or enter value

Bulk Company ID Number*

Driver's License Acknowledgement*

By checking the box below, you acknowledge that you MUST attach a copy of your driver's license to this request. This attachment can be provided towards the bottom of this page.

Failure to provide a copy of your driver's license will deem this request incomplete and we will not be able to process.

You are required to submit an LOP with this request. Otherwise, select 'Attorney in the previous field. Check the box to confirm your understanding.*

Patient Last Name*

Patient First Name*

Patient Date of Birth*

MM/DD/YYYY

Recipient Name*

First and Last

Recipient Email Address*

Recipient Phone Number*

Phone

Recipient Fax Number*

Phone

Recipient Mailing Address 1*

Recipient Mailing Address 2

Recipient Mailing Address City, State, and Zip Code*

Facility Name*

Select

Date(s) of Service*

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

Documents Requested*

Select

Please verify whether you are the Patient listed above or a Qualified Personal Representative.*

(Example: Guardianship of Patient, Executor of Estate, Power of Attorney, Death Certificate) – Qualified Personal Representatives must submit supporting documentation to the Email: MedRecs@gryphonhc.com

Select

Information to be disclosed to:*

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 recipient.

I AUTHORIZE THE USE OR DISCLOSURE OF HEALTH INFORMATION AS DESCRIBED ABOVE.*

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.

File Upload*

Drag and drop files here or

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 will occur if information is incomplete or inaccurate, requiring the submission of a new request at a later date.

HIPAA Verfification*

Kindly review and verify that you have successfully uploaded the completed HIPAA Document.

Check and Upload: Information Verification*

Review all information entered is accurate, including the Date of Birth, Patient Name, Affidavits, HIPAA documents, etc.

Check the box upon completion

Send me a copy of my responses

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