Authorization To Disclose Medical Information Form
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2AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION
From the law firm of: _________________________________________________________
Patient Name: __________________ Health Record Number: _________________________
Date of Birth: ________________________________SS#____________________________
1. I authorize the use or disclosure of the above named individual’s health information as
described below:
2. The following individual or organization is authorized to make the disclosure:
_____________________________________________________________________
3. The type and amount of information to be disclosed is limited to records concerning the
following illnesses/conditions certified for compensation by the September 11th Victim
Compensation Fund________________________________________________, or related
illnesses/conditions. This is a limited records request intended to minimize the administrative
burden, while providing the following information:
Current Diagnosis and severity
Current Medications
Doctor’s Notes and Office Visit/Examination Notes or Records
(if applicable, limited to time period __________________to__________________)
Most recent treatment plans
Surgical and Operative Reports and Discharge Reports
(if applicable, specify specific surgical procedure____________________________)
Emergency Department Visits, Admission Records and Discharge Reports
Visits for Acute Episodes related to the disease or condition
Consultation Reports
(if applicable, specify type of consultations_________________________________)
Pulmonary Function Tests, Diagnostic Imaging, Diagnostic Summary Reports
Disability Evaluations or Reports
Other________________________________________________________________
4. While not specifically requested, 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). I may also include information
about behavioral or mental health services, and treatment for alcohol and drug abuse.
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