Hipaa Medical Authorization Form printable pdf download

“HIPAA” MEDICAL AUTHORIZATION FORM

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND REPORTS

TO EPGX, INC. AND EPGX-SELECTED EXPERTS/PROFESSIONALS

FULL NAME: _________________________________________________________________________

DATE OF BIRTH: ________________________. SOCIAL SECURITY NO.: ______________________

I hereby authorize all health care providers, physicians, hospitals, clinics and institutions, medical facilities,

mental health clinics, mental health hospitals, and pharmacies, to release all existing medical records and

information regarding the above referenced patient’s medical care, treatment, physical/medical condition,

and medical expenses revealed by your observation or treatment of past, present and future to EPGX, Inc.

or its representative, or the bearer hereof, or the bearer of any photo static or Xerox copy hereof.

The purpose of this authorization is to permit EPGX, Inc. as well as experts and/or professionals selected

by EPGX, Inc. to review my medical records and do a medical analysis to advise me as to the likelihood of

symptoms or adverse reactions that I have suffered, which may be linked to particular drugs that I have

taken, and related issues. I understand that this authorization includes information regarding the diagnosis

and treatment of drug, alcohol, Acquired Immune Deficiency Syndrome (AIDS), and psychiatric and

psychological disorders. It also includes genomic information, clinical information, blood tests, x-ray

reports, laboratory reports, CT scan reports, MRI scans, EEG’s, EKG’s, sonograms, arteriograms, fetal

monitor strips, discharge summaries, photographs, surgery consent forms, informed consent forms

regarding family planning, admission and discharge records, operation records, doctor and nurses notes,

prescriptions, medical and any correspondence/memoranda and billing information.

It also includes, to the extent such records currently exist and are in the possession of health care providers,

insurance records, including Medicare/Medicaid and other public assistance claims, applications,

statements, eligibility material, claims or claim disputes, resolutions and payments, medical records

provided as evidence of services provided, and any other document or things pertaining to services

furnished under Title XVII of the Social Security Act or other forms of public assistance (federal, state,

local, etc). This listing is not meant to be exclusive.

I understand that these records may be shared by EPGX, Inc. with experts and/or other professionals –

including potentially for purposes of medico-legal evaluation. Accordingly, I further authorize EPGX, Inc.

to confer with other experts and/or professionals of their choice, including legal professionals who may

assist with the provision of medico-legal analysis pertaining to my adverse reactions, symptomatology or

related issues.

I, the undersigned individual, am on notice that, and agree to, the following:

(1)

I understand that this request seeks disclosure of protected health information, and any

disclosure of the same pursuant hereto is at the request and consent of the undersigned.

(2)

I understand that any health care provider disclosing the above requested information

may not condition treatment, payment, enrollment or eligibility for benefits on whether I

sign this authorization.

(3)

I understand that this authorization can be revoked through written notice to EPGX, Inc.,

except to the extent that action has been taken in reliance on this authorization. The

undersigned is aware of the potential that protected health information disclosed pursuant

to this authorization is subject to re-disclosure in a manner that will not be protected by

HIPAA regulations.

(4)

I understand that a photocopy of this authorization shall be considered as effective and

valid as the original.

(5)

I understand that EPGX, Inc. may share my medical data with other experts and/or

professionals of EPGX, Inc.’s selection, including with legal professionals who may

provide medico-legal analysis evaluating rights I may have based upon my medical data.

Hipaa Medical Authorization Form

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