HIPAA Forms

Authorization to Disclose Health Information

            I, ______________________________________________________________,

                   (patient�s name, date of birth and social security number)

authorize the disclosure by ______________________________________________ to

                                             (individual, organization or institution request directed to)

the law firm of RIEDERS, TRAVIS, HUMPHREY, HARRIS, WATERS & WAFFENSCHMIDT, or any representative thereof, the portions of my health information or records set forth below, and to respond to requests for their opinion regarding my physical or mental condition, including but not limited to opinions regarding my prior medical history, history, findings, interpretation of diagnostic tests or lab results, diagnosis, etiology of my condition, reasonableness and necessity of treatment, need for future treatment (including the nature, frequency and usual and customary charge for such treatment), prognosis and physical limitations (including any disability, impairment or handicap).

            The health information I authorize to be disclosed to the law firm of Rieders, Travis, Humphrey, Harris, Waters & Waffenschmidt, or any representative thereof, is:

• Entire hospital chart, including but not limited to problem list, medication list, history and physical, discharge summary, laboratory results, progress notes, nurses� notes, emergency room records, x-ray and imaging studies, toxicology screens, consultation reports, operative reports, anesthesia records, labor and delivery records, progress records and attending physician reports.

• Pharmacy or prescription records.

• Mental health records, including records from any psychiatrist, psychologist, social worker or other licensed mental health professional or their staff.

• Entire chart of any physician or group of physicians whether operating as a sole proprietorship, partnership or corporation, including records supplied to the physician from any other medical provider, hospital, emergency room, psychiatrist or psychologist, attorney, insurer, or other third party other than the physician or member of the group.

• All diagnostic tests or imaging studies, including but not limited to x-rays, MRI�s, EMG�s, EEG�s, discograms, CAT scans, PET scans, arthrograms, myelograms, diagnostic arthroscopies, ultrasounds, Doppler studies, including both the report of the study and the study itself.

• Entire chart of any physical or occupational therapist or entity, including records supplied to the physical therapist, occupational therapist or physical or occupational therapy group by a physician not a member of the group, a referring physician or from any other medical provider, hospital, emergency room, psychiatrist or psychologist, attorney, insurer, or other third party other than the therapist or member of the entity providing the therapy.

• Entire chart of any chiropractor or group providing chiropractic treatment or services, including records contained in the chart from persons or entities other than the chiropractor or group providing the treatment or services.

• Records of any EMS, BLS or ALS group or unit providing emergency medical care, including the records of any private or public ambulance company or unit.

Rieders, Travis, Humphrey, Harris, Waters & Waffenschmidt has been retained by me to investigate and, if accepted by the firm, initiate and pursue to a conclusion legal claims against individuals, entities or insurers responsible therefore and your full cooperation with them is respectfully requested.  You are further advised to disclose no information to any insurance adjuster or other persons without written authority from me to do so (pursuant to privilege and confidential communication laws, including but not limited to the provisions of HIPAA), with the exception of persons, insurers, or entities from whom you receive a written authorization signed by me that is in compliance with Section 164.508 of HIPAA.

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV).  It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

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 present my written revocation to the health information management department.  I understand that the revocation will not apply to information that has already been released in response to this Authorization.  I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.  Unless otherwise revoked, this Authorization will expire on the following date, event or condition:  _______________________________.  If I fail to specify an expiration date, event or condition, this Authorization will expire in _________________.

I understand that authorizing the disclosure of this health information is voluntary.  I can refuse to sign this Authorization.  I need not sign this form in order to assure treatment.  I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524.  I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.

Date:________________                          _____________________________________

                                                                        Signature of Patient or Legal Representative

Witness:

_____________________________            _____________________________________

                                                          If legal representative, relationship to patient

g:frm:Authorization to Disclose Health Information)

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