VIRGINIA HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE
OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508
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
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
____________ to ______________.
I understand the information to be released or disclosed may include information relating to
sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human
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