HIPAA Compliant Authorization for the Release of Patient Information
Pursuant to 45 CFR 164.508
Claims Department
Plymouth Rock Assurance Corporation, PO Box 9112, Boston, MA 02112-9112
Return This
Form To
Thank you.
CLAIM NUMBER
(12-digit number)
TO
Name of Healthcare Provider / Physician / Facility / Medicare Contractor:
Street Address: City: State: Zip Code:
Patient’s First Name: Patient’s Last 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, reports, 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 providers. 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 handouts/
monographs. 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 (date of loss) / / to (present date) / / . 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: Automobile claim disposition.
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:
To be completed by an authorized representative of Plymouth Rock Assurance
Adjuster’s Name: Name of Representative:
Representative Capacity: (e.g., Attorney, Records Requestor, Agent, etc.)
Street Address: City: State: Zip Code:
I understand the following:
See 45 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 (See 45 CFR § 164.508(c)(1)(vi)) Date
Name of Legally Authorized Representative (See 45 CFR § 164.508(c)(1)(vi)) Relationship
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/ /
Witness Signature Date
All Rights Reserved ©2012 Rev_02_12
