Helotes, TX · Bexar County
Authorization to Use and Disclose Protected Health Information
This authorization lets a patient or representative approve the City of Helotes or Helotes Fire Department to disclose specified protected health information.
What this form is
Use this form to authorize the City of Helotes or Helotes Fire Department to disclose the patient’s protected health information, including records specified in the document, to a named recipient. It asks for patient and recipient details, the information to be released, whether psychotherapy notes are included, and an expiration date. The patient or representative signs and dates the authorization.
Who needs it
A patient or the patient’s representative or guardian can use this form to authorize disclosure of the patient’s protected health information.
How to submit it
The form does not give submission instructions. Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed and dated without a notary; it does not mention any notarized or sworn attachment or related step.
How to submit this form
- 1
Download The Form
Download the Helotes authorization form.
- 2
Complete Patient And Recipient Details
Enter patient identification information and the recipient’s name and address.
- 3
Specify Information And Expiration
Indicate whether psychotherapy notes are included, describe the information to be released, and fill in the expiration date.
- 4
Sign And Date
The patient or the patient’s representative or guardian signs and dates the authorization.
- 5
Submit To The City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What does the Helotes health information authorization do?
- It authorizes the City of Helotes or Helotes Fire Department to disclose the patient’s protected health information to the recipient named on the form.
- Who can sign the authorization?
- The patient can sign, or a patient’s representative or guardian can sign. The signer also provides their printed name and, when applicable, relationship to the patient.
- Do I need a notary for the Helotes health information authorization?
- No. The document calls for the patient or representative to sign and date it; it does not mention a notarized or sworn attachment or related step.
- How do I submit the Helotes health information authorization?
- The form does not state where to submit it. Submit it to the city department named on the form and check the city website for current contact details.