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HIPAA Forms |
In the course of our reviewing the possibility of handling a matter for you, or in representing you, we may receive medical, hospital, psychiatric, or other records protected pursuant to the Health Insurance Portability and Accountability Act of 1996 (�HIPAA�).
While we do not consider ourselves a �covered entity� or a �business associate� of a �covered entity,� nevertheless we want you fully to understand that we may choose to send your records out of the office for review by others such as physicians, counselors, psychiatrists, physical therapists, expert witnesses, potential expert witnesses, other attorneys, adjusters, and the like. We could not possibly list here all uses to which we might put your PHI (Personal Health Information).
By signing this Release and Authorization, you are giving us permission to receive, examine, utilize and send your records to others as we see fit in the course of investigating or handling a matter on your behalf.
You specifically waive any HIPAA requirements which may apply to this firm or others who receive this information. You will not in any way seek to hold this firm responsible for any violation of law with regard to the receipt and use of such information.
This Release and Authorization does not in any way suggest that we are representing you, and this Release/Authorization does not constitute any agreement or contract of representation.
Date:_______________ __________________________
Signature of Patient
Witness: