Legal Medical Information Release Form

Legal Medical Information Release Form

This Medical Information Release Form (the "Authorization") is made and entered into by and between Patient Name: (hereinafter "Patient") and Recipient Name/Organization: (hereinafter "Recipient"), effective as of Effective Date: .

RECITALS

WHEREAS, Patient has medical and billing records, history, and other protected health information maintained by healthcare providers and facilities; and

WHEREAS, Patient desires to permit the disclosure of certain protected health information to Recipient for the purposes described below; and

WHEREAS, Recipient requires access to such information to fulfill the purpose set forth in this Authorization and agrees to receive and handle such information in accordance with applicable law.

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, the parties agree as follows:

1. AUTHORIZATION TO DISCLOSE

Patient hereby authorizes any physician, clinic, hospital, laboratory, mental health provider, insurer, or other health care entity (collectively "Covered Entities") that maintains or controls Patient's protected health information to disclose and release to Recipient the medical information described in Section 2 below. This Authorization specifically includes disclosure by electronic or paper means and includes information collected prior to the Effective Date.

2. DESCRIPTION OF INFORMATION TO BE DISCLOSED

The information to be disclosed includes the following categories (check all that apply) and any records reasonably related to the checked items:

Patient affirms that the boxes checked above accurately reflect the categories of information that Patient authorizes for release. If psychotherapy notes are to be disclosed, Patient must initial here:

3. PURPOSE OF DISCLOSURE

4. EXPIRATION AND REVOCATION

This Authorization shall expire on Expiration Date: , or upon completion of the stated purpose, whichever occurs first. Patient may revoke this Authorization at any time by delivering written notice of revocation to Recipient and to any Covered Entity holding Patient's records. Revocation will not affect disclosures already made in reliance on this Authorization prior to receipt of the revocation.

5. REDISCLOSURE

Patient understands that information disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipient and may no longer be protected by federal law governing health information privacy. Recipient is requested, but not required, to obtain Patient's consent prior to any further disclosure.

6. FEES

Patient acknowledges that reasonable fees may be charged for copying, mailing, or preparing records, consistent with applicable law. If a specific fee arrangement is agreed, indicate here:

7. PATIENT RIGHTS

Patient understands that signing this Authorization is voluntary, that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this Authorization except where permitted by law, and that Patient has the right to inspect and obtain a copy of the protected health information described in Section 2 by requesting it from the Covered Entity that maintains the records.

8. CONDITIONS AND LIMITATIONS

Patient represents that Patient is authorized to sign this Authorization. If Patient is signing as a personal representative, complete Representative Name: and Representative Authority (e.g., guardian, power of attorney): .

9. LIABILITY AND INDEMNITY

Covered Entities and Recipient shall be entitled to rely upon a copy of this Authorization. Patient releases and holds harmless Covered Entities and Recipient from any liability which may arise from disclosure of the information authorized herein, except for disclosures made in bad faith or with willful misconduct. Patient agrees to indemnify Recipient for any claims arising from Patient's representations in this Authorization.

10. NOTICES

11. AMENDMENTS, WAIVER, COUNTERPARTS

This Authorization may be amended only by a written instrument signed by Patient and Recipient. No waiver of any provision hereof shall be effective unless in writing and signed by the party waiving. This Authorization may be executed in counterparts and may be transmitted by facsimile or electronic image, each of which shall be deemed an original.

12. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

Governing Law: This Authorization shall be governed by and construed in accordance with the laws of the state of Jurisdiction: , without regard to conflict of laws 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 to the fullest extent permitted by law.

13. ADDITIONAL PROVISIONS

By signing below, Patient affirms that Patient has read and understands the terms of this Authorization, has had the opportunity to ask questions, and consents to the disclosure of protected health information as set forth herein. Patient acknowledges receipt of a copy of this Authorization.

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