Healthcare Medical Examiner Release

HEALTHCARE MEDICAL EXAMINER RELEASE

Decedent / Patient Information

Decedent/Patient Name:

Date of Birth: Date of Death:

Requestor / Authorized Representative

Proof of authority attached: (e.g., letter of administration, power of attorney, court order)

Recipient / To Whom Records Will Be Released

Records / Materials to Be Released

Complete medical examiner / coroner case file
Autopsy report and findings
Toxicology report(s)
Photographs and video recordings
Microscopic slides and tissue specimens
Radiology studies and imaging
Chain-of-custody and evidence logs
Other:

Date Range / Timeframe

Release records from: through: All dates available

Purpose (Select All That Apply)

Funeral arrangements / disposition
Legal proceedings / litigation
Insurance claim / benefits
Research or educational purposes (requires approval)
Personal copy for family
Other (specify):

Authorization, Limitations, and Certification

I, the undersigned, authorize the Medical Examiner / Coroner office and any treating or forensic providers to disclose the materials described above to the named recipient. This authorization includes release of information and materials that may pertain to communicable disease, mental health, substance use, genetic testing, and HIV/AIDS status where such information is part of the records requested. I understand that such information is protected and may be subject to special confidentiality protections under law.

I certify that I am authorized to request the release of these records for the decedent identified above. I understand that the Medical Examiner / Coroner and associated providers are released from civil and legal liability that may arise from honoring this request, provided they act in good faith reliance on this authorization and any documentation of authority submitted. I further certify under penalty of perjury that the information I have provided on this form is true and correct.

Revocation: I understand I may revoke this authorization at any time by providing written notice to the releasing office, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization.

Fees, Identification, and Redisclosure

I understand that fees for copying, retrieval, and shipping may apply and may be required in advance. I agree to pay the reasonable costs associated with preparing and delivering the requested records unless waived in writing by the releasing authority.

I understand that once disclosed, the recipient may re-disclose protected information and that such re-disclosure may not be protected by privacy laws. I release the Medical Examiner / Coroner and other releasing entities from liability for disclosures made pursuant to this authorization.

Agreement to fees and identification: Requestor agrees to provide government-issued identification and to remit applicable fees.

Acknowledgment of Privacy Notice

By signing below, I acknowledge that I have been informed of the privacy practices applicable to the records released and that I have the right to receive a copy of this authorization upon request.

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