Fillable Authorization To Disclose Medical Information Form (Page 2 of 2) in pdf

Authorization To Disclose Medical Information Form Page 2

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5. This information may be disclosed to and used by me and to the following individuals or

organizations: _____________________________________________________________

Address _____________________________________________________________

City ________________ State ___________ Zip Code ____________________

6. I understand I have the right to revoke this authorization at any time. I understand if I revoke

this authorization I must do so in writing and present my written revocation to the health

information management department. I understand the revocation will not apply to

information that has already been released in response to this authorization. I understand 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.

7. I understand that authorizing the disclosure of this health information is voluntary. I

understand that I have a right to receive a copy of this request and authorization form. I

understand that 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 164.52. I understand any disclosure or information carries with it the

potential for an unauthorized re-disclosure and the information may not be protected by

federal confidentiality rules. If I have questions about disclosure of my health information, I

can contact a health insurance representative or medical provider.

8. These records are being sought by myself and my attorneys in relation to a claim I am

making to the September 11th Victim Compensation Fund, in which I am a claimant.

_____________________________________

____________________________

Claimant Name

Date

________________________________________

___________________________

Signature of Witness

If Signed by Legal Representative, Relationship to Patient

*This authorization is in compliance with the Health Insurance Portability and Accountability

act (“HIPAA”) 46 CFR 164.52.

Authorization To Disclose Medical Information Form Page 2

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