Fill and Sign the Plaintiff Fact Sheet and Accompanying Authorizations PDF 3 Mb Form

Authorization for Use and Disclosure of Protected Health Information under HIPAA RULE 164.508 You May Refuse to Sign This Authorization I, _____________________ (name of patient) (Individual) authorize _______________ __________________________ (name of health care provider) (you) to use and disclose in any form or format a copy of records concerning Individual but only as follows, to: _____________________ (name of recipient) for the purpose(s) of (state specific purposes)____________________________________________________________________________ ____________________________________________________________________________. (description of purposes) ______________________________________________________________________ ________________________________________________________________________________________________________________________________________________________. I specifically authorize you to use and disclose the following types of super-confidential information (initial where appropriate): _____ HIV records (including HIV test results) and sexually transmissible diseases _____ Alcohol and substance abuse diagnosis and treatment records _____ Psychotherapy records _____ Tuberculosis _____ All hospital records _____ All of the above I specifically authorize you to use and disclose the following Protected Health Information. Please initial one or more of the following, if applicable: _____Written Medical Records: _____ X-rays/MRI/CT _____ Billing records _____ Prescription records _____ Other (specify in detail): [description of other protected information] _____________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____ All of the above
I have not yet provided any prior authorization to collect or otherwise use my medical information. (do not provide the initial authorization unless it is in writing or if you have a medical necessity for privacy). If any health care providers collect or obtain personal information from you about an individual without notifying you, ask them to give you prior written authorization for the purpose described above. Ask your personal health care provider to keep a copy of all prior authorization requests they have received. A written authorization from patients has been provided pursuant to HIPAA. A patient must be informed of the purposes for which information is being collected. The following authorization is in the form of a signed letter: name/initials of recipient: (name of health care provider) (individual).