Fill and Sign the Medical Osteopathic Doctors Application Pack Arkansas Form

LIMITED AUTHORIZATION TO INSPECT AND COPY MEDICAL RECORDS (Valid for 60 days from date) TO WHOM IT MAY CONCERN: I, ___________________________________________, hereby authori ze all doctors who have ever treated me and all doctors who have ever treated me and all hospitals at which I have ever been a patient to permit ___________________________________________, or his/her/its attorney or representative, by presenting this signed authorization or a copy thereof, to such doctor or hospital, to obtain a copy of all of said medical records of any nature whatsoever (including medical bills and existing medical opinions) pertaining to any diagnosis, examination, and treatment of me at any time at such hospital or by such doctor or at his direction. T HIS IS NOT AN AUTHORIZATION PERMI TTING ANYONE TO ORALLY DISCUSS MY MEDICAL TREATMENT OR CONDITION WI TH MY DOCTORS OR THE DOCTOR'S PERSONNEL . I GIVE THIS AUTHORIZATION WITH TH E FOLLOWING UNDERSTANDING AND AGREEMENT OF COUNSEL : 1. That ___________________________________________ w ill deliver to my attorney, ___________________________________________, at reas onable cost to me, a copy of all records and documents obtained by use of this authorization; 2. That ___________________________________________ shall a dvise my attorney in writing of all medical providers to whom this author ization is presented, regardless of whether or not medical records are actually reviewed and/or copied. Such writing shall (a) identify the medical provider; (b) give the date of presentation of this authoriza tion; (c) state the name of the person presenting the information and things obtained; 3. That ___________________________________________ shall pr ovide all copies and advisories herein within 20 days from the date of receipt of same; 4. That the parties stipulate that said records satisfy the requirements of Rule 902(10) M ISS . R. E VID . Page -2- 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 gove rned 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 pl an, 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 a nd release to my agent, without restriction, all of my individually identifiable health information and me dical records regarding any past, present or future medical or mental health condition, including all in formation 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. SIGNED AND DATED this the __________ day of ___________________________________________, 20__________. ____________________________________________________ ___________________________________________ SOCIAL SECURITY NUMBER