Legal Medical Records Authorization Form

LEGAL MEDICAL RECORDS AUTHORIZATION FORM

This Medical Records Authorization (the "Authorization") is entered into as of Effective Date: by and between Patient Name: (Patient), Date of Birth: , Releasing Provider/Facility: (Provider), and Recipient of Records: (Recipient).

RECITALS

WHEREAS, Patient is the individual whose protected health information is the subject of this Authorization; and

WHEREAS, Provider maintains health records and other protected health information relating to Patient and is authorized to disclose such records pursuant to Patient's written authorization; and

WHEREAS, Patient desires to permit Provider to disclose certain medical records and information to Recipient for the purpose set forth below, subject to the terms and conditions of this Authorization.

NOW, THEREFORE

In consideration of the mutual covenants and agreements set forth herein, and intending to be legally bound, the parties agree as follows:

1. AUTHORIZATION

Patient hereby authorizes Provider to disclose and release to Recipient the medical information and records described in Section 2 below. This Authorization permits disclosure of records maintained on paper and in electronic form and includes copies, summaries, and abstracts as requested by Recipient.

2. DESCRIPTION OF INFORMATION TO BE DISCLOSED

Common categories include: history and physical, progress notes, discharge summary, operative reports, laboratory and pathology reports, imaging studies and reports, billing records, and medication records. If left blank, Recipient shall be authorized to request full medical record as reasonably necessary for the Purpose specified below.

3. PURPOSE OF DISCLOSURE

Purpose:

4. SENSITIVE INFORMATION

Special categories of health information (such as substance use disorder treatment records, psychotherapy notes, HIV/AIDS-related information, and genetic testing results) require explicit authorization. Patient must indicate consent for release of each category below by checking the box and initialing in the adjacent field.

Include substance use disorder treatment records — Initials:

Include mental health/psychotherapy notes — Initials:

Include HIV/AIDS-related information — Initials:

5. DURATION AND EXPIRATION

This Authorization shall be effective as of the Effective Date set forth above and shall expire on: . If no expiration date is provided, this Authorization will expire 365 days from the Effective Date.

6. REVOCATION

Patient may revoke this Authorization at any time by providing a written revocation signed by Patient or Patient's authorized representative to Provider. Revocation will not affect disclosures already made in reliance on this Authorization prior to Provider's receipt of the revocation. To revoke, contact:

7. REDISCLOSURE

Patient understands that information disclosed pursuant to this Authorization may be subject to redisclosure by Recipient and may no longer be protected by federal or state privacy laws. Recipient shall not be bound by Provider's confidentiality obligations once information is disclosed and Patient releases Provider from liability for redisclosure consistent with applicable law.

8. FEES AND CHARGES

Provider may charge reasonable copying and administrative fees for preparation and delivery of records. Patient agrees to pay permitted fees unless waived by Provider. Any disputes regarding fees shall be handled in accordance with applicable law.

9. NO CONDITIONING OF TREATMENT

Provider may not condition treatment, payment, enrollment, or eligibility for benefits on Patient's signing of this Authorization, except where allowed by law for research-related treatment or where the provision of health care is solely for the purpose of creating records for a third party.

10. REPRESENTATIONS AND AUTHORITY

Patient represents that the information provided in this Authorization is true and that Patient has the authority to authorize release of the protected health information described herein. If an authorized representative signs on behalf of Patient, the representative represents that he or she has legal authority to do so and will provide documentation of such authority upon request.

11. NOTICES

Any notice pursuant to this Authorization shall be delivered in writing to the contact information provided by the parties. Patient contact address and phone for purposes of notices:

12. MISCELLANEOUS

Governing Law: This Authorization shall be governed by and construed in accordance with the laws of the state in which Provider maintains the medical records, without regard to conflicts of law principles.

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

Severability: If any provision of this Authorization is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect and shall be construed so as to carry out the intent of the parties as nearly as possible.

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

CERTIFICATION

By signing below, Patient (or Patient's authorized representative) certifies that he or she has read and understands this Authorization, that the information provided is accurate, and that the signature constitutes a valid authorization for the release of the categories of information specified above. Patient understands that signing this Authorization is voluntary and that a copy of this document shall be valid as the original.

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