Notices_TRS Form 628

*+628+
TEACHER RETIREMENT SYSTEM OF TEXAS
1000 Red River Street, Austin, Texas 78701-2698
Telephone (512) 542-6400 or 1-800-223-TRST (8778)
www.trs.state.tx.us
TRS 628
05-03
NOTICES
1. You have the right to revoke this authorization for the release of protected health care
information at any time and prevent future releases of your confidential health care
information. This revocation will not affect any release(s) of protected health care
information that TRS has made in reliance on the authorization. The revocation must
be in writing, state clearly which authorization you are revoking, and be signed by you
or a person authorized to sign on your behalf.
2. TRS may not condition treatment, payment, enrollment, or eligibility for benefits on
whether you sign an authorization for the release of protected health information.
3. Protected health information that TRS discloses in response to this authorization may
be redisclosed by the person or entity to whom TRS discloses the information. In that
event, the information may no longer be protected by the HIPAA privacy rule.
Reverse of Form
TRS 628
05-03
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
I,
, Social Security No.
,
(your name)
hereby authorize the Teacher Retirement System of Texas, its employees, and agents to release to
(name of person or company to receive information and their address, including street address, city, state, and zip code)
the following information (please describe specifically the information you are authorizing to be released):
for the following purpose (if you prefer not to reveal the purpose, you may state "at my request"):
This authorization expires (please list a specific date or a specific event when you want this authorization to terminate):
Signature of person authorizing release
Date
If the person signing this authorization is not the person to whom the requested information
relates, please provide a description of your authority to act for the person whose information
is requested to be released and attach any documents authorizing you to act on behalf of the
individual, such as a power of attorney or letters of guardianship: