TO: ______________________________________________________________________
Name of Healthcare Provider/Physician/Facility/Medicare Contractor
Street Address
City, State and Zip Code
RE: Patient Name: __________________________________________________________
Date of Birth: _________________ 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:
All medical records, meaning every page in my record, including but not limited to:
office notes, face sheets, history and physical, consultation notes, inpatient, outpatient
and emergency room treatment, all clinical charts, r ports, order sheets, progress notes,
nurse's notes, social worker records, clinic records, treatment plans, admission records,
discharge summaries, requests for and reports of consultations, documents,
correspondence, test results, statements, questionnaires/histories, correspondence,
photographs, videotapes, telephone messages, and records received by other medical
All physical, occupational and rehab requests, consultations and progress notes.
All disability, Medicaid or Medicare records including claim forms and record of denial
of benefits.
All employment, personnel or wage records.
All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records
and specimens; radiology records and films including CT scan, MRI, MRA, EMG,
bone scan, myleogram; nerve conduction study, echocardiogram and cardiac
catheterization results, videos/CDs/films/reels and reports.
All pharmacy/prescription records including NDC numbers and drug information
All billing records including all statements, insurance claim forms, itemized bills, and
records of billing to third party payers and payment or denial of benefits for the period
____________ to ______________.
I understand the information to be released or disclosed may include information relating to
sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human
Page 1 of 2
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
Representative Capacity (e.g. attorney, records requestor, agent, etc.)
Street Address
City, State and Zip Code
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
c. My treatment or payment for my treatment cannot be conditioned on the signing of this
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 Date
(See 45CFR § 164.508(c)(1)(vi))
Name and Relationship of Legally Authorized Representative to Patient
(See 45CFR §164.508(c)(1)(iv))
___________________________________________ ______________________
Witness Signature Date
Page 2 of 2
Form Made Fillable by eForms
click to sign
click to edit
click to sign
click to edit