Fill and Sign the Authorization Release Records Form

AUTHORIZATION TO RELEASE MEDICAL RECORDS TO: RE: This will authorize ________________________________ , who has treated me, to release to the law firm of ________________________________ , whom I have employed, any and all information relative to my physical condition, past, present, or future, including copies of X-ray reports, laboratory reports, doctors' reports, doctors' notes, nurses' notes, medical history, and all other records. You are further authorized to freely discuss with any member of said law firm, any and all aspects of my illnesses, accidents, treatments, and to answer any and all questions which they may have relative to my condition and the circumstances surrounding it. I specifically request that you void any prior medical releases and, in addition, request that you release no other medical information to anyone other than ________________________________ (firm), ________________________________ (address), ________________________________ (city), Alabama _______________ (zip code). A copy of this release will have the same effect as an original. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. _____________________________ Signed this _________ day of __________________, ____________, in the presence of _____________________. _____________________________ Witness