Authorization Form

Authorization for the release of Medical Records

*Please enter your information in the form and submit to a physician to obtain your medical records.

 

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT
INFORMATION PURSUANT TO 45 CFR 164.508

 

TO:  (required)  (Name of Healthcare Provider/Physician/Facility/Medicare Contractor)
 
TO:  (required)  (Address)
 
TO:  (required)  (City, State and Zip Code)

RE:  (required)  (Patient Name)
 
TO:  (required)  (Date of Birth)
 
TO:  (required)  (Social Security Number)

I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

to .

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.

This protected health information is disclosed for the following purposes: .

This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.

You are authorized to release the above records to the following representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:

Name of Representative (required)

Representative Capacity (e.g. attorney, records requestor, agent, etc.) (required)

Street Address (required)

City, State and Zip Code (required)

I understand the following: See CFR §164.508(c)(2)(i-iii)

a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
b. The information released in response to this authorization may be re-disclosed to other parties.
c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.

Signature of Patient or Legally Authorized Representative (required) (See 45CFR § 164.508(c)(1)(vi))

Date (required)

Name and Relationship of Legally Authorized Representative to Patient (required) (See 45CFR §164.508(c)(1)(iv))

Signature (required)

Witness Signature (required)

Date (required)


 
 
 

Your Name (required)

Your Email (required)

Contact Number (required)

Input this Code (required)
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