San Antonio Counseling & Behavioral Center

PATIENT AUTHORIZATION FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby authorize San Antonio Counseling and Behavioral Center, and VCounselors located at, 5522 Lone Star Pkwy, #303, San Antonio, TX 78253 to: Release or Disclose records from the entity listed below regarding the health information of the patient below. Obtain or Request records from the entity listed below regarding the health information of the patient below.

Indicate below the name of the individual, faculty or organization authorized to receive or disclose information: 

  1. I understand these records include drug/ alcohol/ mental health/ communicable disease related information I understand that information release could contain reference to or results of HIV antibody testing.

  2. I understand that this information is confidential and protected by federal law. I understand that the potential exists for health information that is release with my authorization to be re-disclosed by the recipient. and to be no longer protected by the Federal HIPAA law.

  3. A photocopy of this authorization should be considered as a valid as the original. I understand that this consent is subject to revocation by the undersigned at any time except to the extent that action had been taken in reliance hereon and in any event. shall expire one (1) year from the date of signature.

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