PROTECTED HEALTH INFORMATION DISCLOSURE AUTHORIZATION
(HIPAA COMPLIANT: 45 CFR §164.508)
Patient’s name :
Date of Birth : ______________________________________________________________________
1. Disclosure of PHI authorized from (45 CFR 164.508(C)(1)(ii)):
2. Disclosure authorized to George W. Conley, Esquire, 10 Dakota Trail, Medford, NJ 08055, “my lawyers,”
and/or its employees acting within the course and scope of their employment with “my lawyers.” 45 CFR 164.508(C) (1) iii).
3. Documentation for disclosure: My entire medical chart & patient account information, including but not
limited to, (A) a copy of the entire chart, including the jacket thereof, (B) copies of any diagnostic materials including x-rays, MRI’s,
CT scans, etc..., and the reports thereon, (C) correspondence, telephone messages or other documented notes, (D) Patient
questionnaires or intake information forms, (E) medication lists, (F) office visit notes, sign-in forms, operative reports, consultation
notes, lab results, (G) photographs of any kind, (H) charges for services and any payments thereon, including HCFA’s and any other
billing information. 45 CFR 164.508(C) (1) (I).
Further, you authorized to provide “my attorneys” with office conferences, telephone conferences, and medical reports. You
authorized to provide testimony at deposition or trial as requested by “my attorneys.” I understand and recognize that this
Authorization shall operate to result in disclosure of otherwise confidential information related to sexually transmitted disease; acquired
immunodeficiency syndrome; human immunodeficiency syndrome; substance abuse, addiction or treatment; as well as behavioral
and/or mental health evaluations and information.
4. Purpose for disclosure: For use by “my attorneys” in a civil action or as evidence in a legal claim or proceeding.
45 CFR 164.508(C) (1)(iv).
5. Expiration of this Authorization: Valid for a period of five (5) years from the date signed, unless earlier revoked
in writing by me. 45 CFR 164.508(C) (1) (v). I understand that I have the right to revoke this Authorization by way of delivering a
signed and dated Revocation of Authorization to the healthcare provider named above, 45 CFR 164.508(C)(2)(i), but that this
Authorization can not be revoked as to Protected Health Information which has been previously released in reliance on this document.
45 CFR 164.508(B)(5).
6. Re-Disclosure acknowledgment: Acknowledge awareness that once Protected Health Information has
disclosed it may be re-disclosed by the recipient and no longer am subject to the protections of Federal law. 45 CFR 164.508(C) (2)
7. Voluntaries: I voluntarily signed this Authorization and acknowledge I am aware that my refusal to sign this
Authorization will not result in a denial of health care by any hospital or health care provider. This Authorization has not been coerced
by any health care entity or any of its business associates. 45 CFR 164.508(C) (2)(ii).
The Protected Health Information authorized for disclosure shall be provided to my attorneys within the time frames set forth
in 45 CFR 164.524(b)(2).
Any fax and/or copy of this Authorization shall be treated as an original document.
Printed name: _____________________________________
Date of Birth: ______________________________________
Soc. Sec. No.: _____________________________________