Legal Medical Authorization Form

LEGAL MEDICAL AUTHORIZATION FORM

Patient Name:   Date of Birth: / /

Patient Address:

Recipient/Facility Name:   Recipient Address:

RECITALS

WHEREAS, Patient Name: is the individual whose health information is described below; and

WHEREAS, Recipient/Facility Name: is authorized to receive and use the information for the purposes set forth herein; and

WHEREAS, the Patient desires to authorize the disclosure of certain protected health information in accordance with applicable law and the terms of this Authorization.

NOW, THEREFORE, in consideration of the mutual covenants set forth below, the parties agree as follows:

1. AUTHORIZATION

The Patient hereby authorizes all treating physicians, hospitals, clinics, laboratories, pharmacists and other healthcare providers and their agents (collectively, "Providers") to disclose and release to Recipient/Facility Name: the protected health information described in Section 2 below.

2. DESCRIPTION OF INFORMATION

The information to be disclosed includes (check all that apply):

Medical history and office notes
Laboratory, imaging, and diagnostic reports
Discharge summaries and operative reports
Mental health records (if applicable)
HIV/AIDS related records (if applicable)
Substance use disorder treatment records (if applicable)
Other:

The Patient authorizes the release of the records described above for the period from / / through / / , or for all past and future treatment if no dates are specified.

3. PURPOSE

Purpose of Disclosure: . If no purpose is specified, release is authorized for continuity of care and legal/administrative reasons related to Patient's care.

4. EFFECTIVE DATE AND EXPIRATION

This Authorization is effective as of / / and expires on / / , unless revoked earlier in writing in accordance with Section 5 below.

5. REVOCATION

The Patient may revoke this Authorization at any time by delivering a written revocation to the Provider or Recipient identified above. Revocation is not effective to the extent that action has already been taken in reliance on this Authorization, nor where the Authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

6. REDISCLOSURE

Information disclosed pursuant to this Authorization may be subject to redisclosure by the Recipient and may no longer be protected under applicable federal privacy laws. Special categories of information (mental health, HIV/AIDS, substance use disorder) are particularly sensitive and will be disclosed only if expressly authorized above; such information may be subject to additional state protections which the Recipient must honor where applicable.

7. FEES

The Recipient may be charged a reasonable fee for copying and postage in accordance with applicable law. The Patient will be informed of any such fees prior to release, except where prohibited by law.

8. CONDITIONS AND CERTIFICATION

The Patient certifies that the foregoing is true and correct, that the Patient has had the opportunity to ask questions regarding this Authorization, and that the Patient understands the nature and consequences of authorizing the release of the specified health information. The Patient understands that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this Authorization except where expressly permitted by law.

9. REPRESENTATIVE AUTHORITY

If signed by a personal representative, the representative certifies that the authority to act on behalf of the Patient is valid under applicable law and agrees to provide documentation of such authority upon request.

10. NOTICES

Notices to the Patient shall be sent to:

Notices to the Recipient shall be sent to:

11. WARRANTIES, GOVERNING LAW, AND MISCELLANEOUS

Governing Law: This Authorization shall be governed by and construed in accordance with the laws of the state in which the Patient resides, without regard to conflict of law principles.

Entire Agreement: This Authorization constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements and understandings, whether written or oral.

Severability: If any provision of this Authorization is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Amendments and Waiver: Any amendment to this Authorization must be in writing and signed by the Patient. No waiver of any provision is effective unless in writing signed by the waiving party.

12. ATTESTATION

By signing below, the Patient (or personal representative) attests that they have read and understand this Authorization, that the information provided is accurate to the best of their knowledge, and that they authorize the release as indicated.

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