Hipaa Compliant Authorization Form For The Release Of Patient printable pdf download

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT

INFORMATION PURSUANT TO 45 CFR 164.508

TO:

______________________________________________________________________

Name of Healthcare Provider/Physician/Facility/Medicare Contractor

______________________________________________________________________

Street Address

______________________________________________________________________

City, State and Zip Code

RE:

Patient Name: __________________________________________________________

Date of Birth: _________________ Social Security Number: _____________________

I authorize and request the disclosure of all protected information for the purpose of

review and evaluation in connection with a legal claim. I expressly request that the designated

record custodian of all covered entities under HIPAA identified above disclose full and complete

protected medical information including the following:

All medical records, meaning every page in my record, including but not limited to:

office notes, face sheets, history and physical, consultation notes, inpatient, outpatient

and emergency room treatment, all clinical charts, r ports, order sheets, progress notes,

nurse's notes, social worker records, clinic records, treatment plans, admission records,

discharge summaries, requests for and reports of consultations, documents,

correspondence, test results, statements, questionnaires/histories, correspondence,

photographs, videotapes, telephone messages, and records received by other medical

providers.

All physical, occupational and rehab requests, consultations and progress notes.

All disability, Medicaid or Medicare records including claim forms and record of denial

of benefits.

All employment, personnel or wage records.

All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records

and specimens; radiology records and films including CT scan, MRI, MRA, EMG,

bone scan, myleogram; nerve conduction study, echocardiogram and cardiac

catheterization results, videos/CDs/films/reels and reports.

All pharmacy/prescription records including NDC numbers and drug information

handouts/monographs.

All billing records including all statements, insurance claim forms, itemized bills, and

records of billing to third party payers and payment or denial of benefits for the period

____________ to ______________.

I understand the information to be released or disclosed may include information relating to

sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human

Page 1 of 2

Hipaa Compliant Authorization Form For The Release Of Patient