The Smith Law Firm: HIPAA Medical Release

HIPAA Privacy Authorization For Disclosure of Protected Health Information Relevant To Litigation or Pending Claims
Please select which case you are participating in.*
Are you signing for your own case or on behalf of a family member?*
(For example, NEC cases select "Family Member" to represent injured child)
If filling this out for you, please type in "Self" here.*
What is your Relationship to the Injured Party?*

HIPAA Privacy Authorization For Disclosure of Protected Health Information Relevant To Litigation or Pending Claims
Injured Party First and Last Name*
Injured Party First and Last Name*
Injured Party Street Address, City, State and Zip*
Injured Party Date of Birth*

MonthDayYear
1. I make the Authorization for the purpose of copying records in connection with a lawsuit or claim to which I am a party.

2. This authorization is directed to and applies to protected health information maintained by: (Hospital Physician Medical Provider, etc.)

3. I hereby authorize the above, its director, administrative and clinical staff or assignees, medical information services and billing department to release any and all medical records and information relating to my care and treatment including x-rays, photographs, electronic and digital files and any other records, unless I expressly direct or specify otherwise. I understand that medical information may include records, if any, relating to treatment of alcohol and drug abuse protected under the regulations in 42 C.F.R. Part 2; psychiatric/psychological services and social work records and any information regarding communicable diseases and infections, tuberculosis, venereal diseases, sexually transmitted diseases, acquire immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV) or ARC.

4. HITECH ACT: I am represented by The Smith Law Firm, PLLC. This is a medical authorization that I have executed in their favor and which allows you to release my confidential medical information directly to them. Pursuant to the HITECH Act, 42 USC § 17935 (e)(1) and its implementing regulations (45 CFR 164.524(c)(4)(i)), I am requesting, in an electronic format only, a complete copy of my medical records for the time period specified below. Please send the below-described records in a PDF file format. I am happy to pay for the costs associated in doing so, as long as the costs are limited to the labor associated in creating that file and either sending it on a CD or in a similar format (i.e. online server or e-mail).

5. This information is to be released for copying purposes to my Attorney(s) The Smith Law Firm. PLLC.

6. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by the federal privacy regulations. Privacy Rule, 45 C.F.R. § 164.508(c)(2).

(CLIENT NOTE: the following date fields are intentionally blank to allow for any future requests that may become necessary)

7. This authorization shall be in force and in effect until the conclusion of the pending litigation or, in the alternative, until the following specific date:___________________. This authorization covers all dates of service, unless otherwise specified: _____________ to __________________.

8. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and send it to the hospital, doctor, or other custodian of medical information. I understand that the revocation will not apply to information that has already been released in response to this authorization.

9. The covered entity to whom this authorization is directed may not condition treatment, payment, enrollment, or eligibility of benefits on whether or not the patient signs the authorization.

10. A copy of this authorization is as valid as the original.
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HIPAA Privacy Authorization For Disclosure of Protected Health Information Relevant To Litigation or Pending Claims

HIPAA Privacy Authorization For Disclosure of Protected Health Information Relevant To Litigation or Pending Claims