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AUTHORIZATION TO PERMIT INTERVIEW OF TREATING PHYSICIAN BY DEFENSE COUNSEL

Physician’s name and address

You are hereby authorized to discuss certain medical condition(s) involving

with

Patient’s name

who is an attorney

Defense Attorney’s Name and Address

in a

representing

Defendant’s name

Type of Lawsuit

brought by

against

Plaintiff(s) Name

Defendant(s)

The lawsuit is currently pending and is at

Stage of Proceeding

YOU ARE PERMITTED TO DISCUSS ONLY THE FOLLOWING MEDICAL CONDITIONS WHICH ARE THE

SUBJECT MATTER OF THE AFOREMENTIONED LAWSUIT:

1. NOTHING CONTAINED HEREIN AUTHORIZES YOU TO DISCUSS ANYTHING ABOUT THIS PATIENT OTHER

THAN THE ABOVE-STATED MEDICAL CONDITIONS.

2. THE PURPOSE OF THIS INTERVIEW IS TO ASSIST THE DEFENDANT(S) IN THE DEFENSE OF THIS

LAWSUIT BROUGHT BY THIS PATIENT. THIS AUTHORIZATION IS NOT AT THE REQUEST OF YOUR

PATIENT.

3. YOUR WILLINGNESS TO PARTICIPATE IN THIS INTERVIEW IS ENTIRELY VOLUNTARY. YOU ARE FREE

TO DECLINE THE REQUEST FOR SAID INTERVIEW.

4. You are permitted to disclose information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except

psychotherapy notes, and CONFIDENTIAL HIV RELATED INFORMATION only if specifically initialed below:

(Indicate by Initialing):

Alcohol/Drug Treatment;

Mental Health Information;

HIV-Related Information

5. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient

is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I

understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization.

If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State

Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These

agencies are responsible for protecting my rights.

6. I have the right to revoke this authorization at any time by writing to the health care provider listed. I understand that I may

revoke this authorization except to the extent that action has already been taken based on this authorization.

7. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for

benefits will not be conditioned upon my authorization of this disclosure.

8. Information disclosed under this authorization might be redisclosed by the recipient (except as noted in Item 5 above), and this

redisclosure may no longer be protected by federal or state law.

9. If not the patient, name of person signing form:

10. Authority to sign on behalf of patient:

11.Date this authorization will expire:

Signature

Date

UCS-575 (2/08)

Form Ucs-575 - Authorization To Permit Interview Of Treating Physician By Defense Counsel

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