Fill and Sign the Medical Authorization Sample Form

MEDICAL AUTHORIZATION TO: _______________ _______________ _______________ ___________ , LA ________ RE: _______________ Medical Records You are hereby authorized and directed to permit the examination of and the copying or reproduction in any manner, whether mechanical, photographic, or otherwise, by my me or such other person as I may authorize, all or any portions desired by me of the following: a. Hospital records, x-rays, x-ray readings and reports, laboratory records and reports, all tests of any type and character, and reports pertaining to hospitalization, history, condition, treatment, diagnosis, prognosis, etiology or expenses; b. Medical records, including patient's record cards, x-rays, x-ray readings and reports, laboratory records and reports of all tests of any type and character, and reports thereof, statements of charges, and any and all of my records pertaining to medical care, history, condition, treatment, diagnosis, prognosis, etiology or expenses. You are further authorized and directed to furnish oral and written reports to me, or my delegate, as requested by me for any of the foregoing matters. I also authorize my attorney(s) or their delegate to photograph my person while I am present in any hospital. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. ________________________________ _______________