COMPLIANT AUTHORIZATION FOR RELEASE OF INFORMATION PURSUANT TO 45 C.F.R. 164.508
Identification: Date of Birth Date of Death Soc. Sec.
Parents Name/Previous Name(s)
(Who is releasing
(to whom the information
will be provided)
Address 651 Allendale Road
King of Prussia, PA 19406
I authorize the disclosure of all protected medical information, from the time period 1998 to present, in written or electronic form
for the purpose of review and evaluation in connection with a legal claim. I expressly request that all covered entities under
HIPAA identified above disclose full and completed protected health information, including, but not limited to, the following:
• All medical records, including, but not limited to: inpatient, outpatient & emergency room treatment; all clinical charts,
reports, documents, correspondence, test results, statements, questionnaires/histories, office and doctor’s handwritten
notes; and records received from other physicians or health care providers;
• All laboratory, histology, cystology, pathology, radiology, CT Scan, MRI, echocardiogram & cardiac catheterization reports;
• All radiology films; myelograms; CT Scans; photographs; bone scans; pathology, cytology, histology, autopsy, immuno-
• All pharmacy prescription records, including, but not limited to: NDC numbers and drug information handouts/monographs
• All billing records, including, but not limited to: all statements, itemized bills, and insurance records.
• All documents related to amendment of any record requested.
Purpose of Release: For the purpose of review and evaluation in connection with a legal claim.
This authorization expires when the following event occurs: the resolution of litigation. I understand that I may revoke this authorization at any time, except to the
extent that action has already been taken in reliance upon it, by giving written notice to RecordTrak. I understand that the covered entity to whom this
authorization is directed may not condition treatment, payment, enrollment or eligibility benefits on whether or not I sign the authorization. This information, once it
is released, may be re-disclosed by the recipient, and if re-disclosed, the information would no longer be protected by the federal privacy rule. Any facsimile, copy
or photocopy of the authorization authorizes you to release the records requested herein.
Signature of Patient if 18 years of age or older
Signature of Parent or Legal Representative
Relationship to Patient, if not signed by Patient
SPECIFIC authorization for release of information protected by state or federal law In addition to the authorization and other provisions contained above,
hereby incorporated by reference, I authorize: (i) the release of data and information to RecordTrak; and (ii) RecordTrak’s re-disclosure of the data
and information to its consultants, experts, agents, and/or other counsel; any and all data, notes, records, reports, and/or any other documents and
information relating to:
X 1. Substance Abuse (Alcohol/Drug) X 2. Mental Health (includes psychological testing) X 3. HIV-related information (AIDS related testing)
This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected
by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42 C.F.R. Part 2) and state requirements prohibit
further disclosure without specific written consent of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for the release
of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or
mental health information. Federal regulations state that any person who violates any provision of this law shall be fined not more than $500, in the case of a first
offense, and not more than $5000 in the case of each subsequent offense. Drug Abuse Office and Treatment Act of 1972 (21 U.S.C. 1175); Comprehensive
Alcohol Abuse Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (42 U.S.C. 4582).
Signature of Patient if 18 years of age or older _________
Signature of Parent or Legal Representative ___________
Relationship to Patient, if not signed by Patient ___________