Hipaa Compliant Authorization Form printable pdf download

HIPAA COMPLIANT AUTHORIZATION FORM PURSUANT TO 45 CFR 164.508

Name and address of the person or provider authorized to make the requested disclosure:

Provider:

Address:

_____________________________________________

Patient name:

Date of Birth: ___________

Social Security Number: ________________

I authorize the disclosure of all protected medical and/or insurance information between the dates of

___________ _________for the purpose of review and evaluation in connection with a legal claim. I expressly

request that all covered entities under HIPAA identified above disclose full and complete protected medical

information, including the following:

•

All medical records, including inpatient, outpatient and emergency room treatment, all clinical charts,

reports, documents, correspondence, phone notes, test results, statements, questionnaires/histories, office

and doctor's handwritten notes, and letters or records received by other physicians.

•

All autopsy, laboratory, histology, cytology, pathology, radiology, CT Scan, MRI, echocardiogram and

cardiac, catheterization reports.

•

All radiology films, mammograms, myelograms, CT scans, photographs, bone scans,

pathology/cytology/histology/immunohistochemistry specimens, cardiac catheterization

videos/CDs/films/reels, and echocardiogram videos.

•

All pharmacy/prescription records including NDC numbers and drug information handouts/monographs.

•

All billing records including all statements, itemized bills, and insurance records.

•

All records of any samples of prescription medicines provided.

•

This authorization applies to psychotherapy notes, and psychiatric or psychological records.

•

Information regarding HIV/AIDS and/or substance abuse may be disclosed.

I authorize you to release the protected health information to the following, who have agreed to pay

reasonable charges made by you to supply copies of such records:

Catherine B. Stevens

Medical Research Consultants

RecordTrak

Quinn Emanuel Urquhart & Sullivan LLP

10114 W Sam Houston Parkway South

651 Allendale Road

51 Madison Avenue, 22

Floor

P.O. Box 61591

Suite 200

King of Prussia, PA 19406

New York, NY 10010

Houston, TX 77099

I acknowledge the right to revoke this authorization by writing to the attorney at the above-referenced

address. However, I understand that any actions already taken in reliance on this authorization cannot be reversed,

and my revocation will not affect those actions. I acknowledge the potential for information disclosed pursuant to

this authorization to be subject to redisclosure by the recipient and no longer be protected under 45 CFR 164.508. I

understand that the covered entity to whom this authorization is directed may not condition treatment, payment,

enrollment or eligibility benefits on whether or not I sign the authorization. Any facsimile, copy or photocopy of the

authorization shall authorize you to release the records herein. This authorization remains in effect for the duration

of my litigation involving Pfizer Inc.

Signature of Patient or Personal Representative

Dated

Name of Patient or Personal Representative

Description of Personal Representative’s Authority to Sign for Patient

Hipaa Compliant Authorization Form

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