Healthcare Medical Malpractice Packet

HEALTHCARE MEDICAL MALPRACTICE PACKET

Patient Information

Patient Name:

Emergency Contact

Insurance Information

Incident and Claim Details

Date of Incident:

Medical Treatment Sought / Providers Involved

Name(s) of treating provider(s) or facility(ies):

Medical Records Release Authorization

I hereby authorize all healthcare providers, hospitals, clinics, laboratories, and insurers that have records or knowledge relating to my care to disclose such records and information to the authorized recipient named below for the purpose of investigation, review, legal representation, settlement, and litigation preparation.

This authorization permits disclosure of all protected health information described above including information relating to communicable diseases, behavioral health, substance use disorder, HIV/AIDS status, and genetic testing unless specifically excluded by state law. I understand that some categories identified may require additional authorization by law; if applicable, my initials are required next to the sensitive categories.

HIPAA Authorization & Acknowledgment

I authorize the use and disclosure of my protected health information (PHI) as described in this packet for the purposes of case evaluation, negotiation, and legal proceedings. I understand that records disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy regulations.

I understand that signing this authorization is voluntary and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits. I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. To revoke, submit a written notice to the authorized recipient identified above. Revocation is not effective to the extent that information has already been released in reliance on this authorization.

Statement of Damages and Relief Sought

Certification, Representations, and Notices

By signing below I certify under penalty of perjury that the information provided in this packet is true and correct to the best of my knowledge. I represent that I am the patient identified herein or the authorized personal representative of the patient. If I am signing as a personal representative, I warrant that I have authority to execute this authorization on the patient's behalf and will provide documentation of such authority upon request.

I acknowledge that this packet does not constitute a settlement, release, or waiver of any rights or claims. Signing this packet authorizes disclosure of protected health information to the authorized recipient for the stated purposes and does not obligate the recipient to pursue any particular course of action. I further understand that copying fees or reasonable administrative fees may be charged by record holders and that I may be responsible for such charges unless otherwise agreed in writing.

I agree to hold harmless and indemnify any healthcare provider who discloses records pursuant to this authorization in good faith, to the extent permitted by law, from any claims arising from such disclosure consistent with the scope of this authorization.

Authorization Duration & Revocation

This authorization is effective immediately upon my signature and shall expire on: . If no date is provided, this authorization will expire one year from the date of signature unless earlier revoked in writing.

Additional Statements

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