HIPPA medical records authorization by paulscallanjr


HIPPA medical records authorization

More Info
I, ___________________________, DOB:_____________, SSN: _______________________; (hereinafter referred to as “Individual”) do hereby authorize______________________________________, ____________________________hereinafter collectively referred to as “you”) to disclose in any form or format a copy of protected health information records for Individual, but only to: ______________________________ ____________________________________________ for the purpose of: civil litigation. I authorize you to use in place of a signed original of this form a xerographic copy of this Release. I specifically authorize you to use and disclose the following types of super-confidential information (initial where appropriate): ___ HIV records (including HIV test results) and sexually transmissible diseases ___ Alcohol and substance abuse diagnosis and treatment records ___ Psychotherapy records ___ Tuberculosis _X_ All hospital, doctor, and/or other medical treatment records ___ All of the above I specifically authorize you to use and disclose the following Protected Health Information. Please mark one or more of the following, if applicable: ___ Written Medical records ___ X-rays/MRI/CT ___ Billing records ___ Prescription records ___ Other (specify in detail): _______________________________________________________ _X_ All of the above I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law; that this Authorization remains effective for one (1) year from the date of signing below; or until the following date: _______________; or until you actually receive a signed revocation; or until the records retention period required under applicable Federal and/or State law has expired, whichever first occurs; that I have been given an opportunity to ask questions about this release of information; that I have received a copy of the signed Authorization; that I may inspect a copy of my protected health information to be used or disclosed under this Authorization; and that I may refuse to sign this Authorization. I understand that I may inspect or copy the information that is used or disclosed. I understand that I may revoke this Authorization at any time by notifying you in writing, except to the extent that action has been taken in reliance on this Authorization. A copy of this signed form will be provided to me for my records. ___________________________________________________ NAME OF PATIENT Date: _____________

WITNESSES: ___________________________________________________ (Please print name and sign) ___________________________________________________ (Please print name and sign) Date: _____________

Date: _____________

To top