Fill and Sign the Release Authorization Form Cookeville Regional Medical Center

- 1 - AUTHORIZATION FOR MEDICAL INFORMATION (Complete copies of all medical records) NAME: ______________________________ DATE OF BIRTH: ______________________________ SOCIAL SECURITY: ______________________________ DATE: ______________________________ TO: ANY PHYSICIAN, HOSPITAL OR CLINIC This is to advise that I have employed the firm of ______________________________, to represent me in connection with a claim for in juries, which I have sustained on or about the _________ day of ______________________________, 20_________, which said injuries were the subject of the treatment and examinati on by professionals while at your facility. My attorneys are desirous of obtaining information as to the examination and treatment of me for those injuries, and I hereby consent and authorize you to turn over to them or any individual in their office, any information which you have concer ning my said injuries and the examination or treatment thereof. I request that you allow them to view your records concerning these injuries and talk with you about it and request your cooperation with them. HIPAA Release Authority. My agent shall be treat ed as I would be with respect to my rights regarding the use and disclosure of my indivi dually identifiable health information or other medical records. This release authority app lies to any information governed by the Health Insurance Portability and Accountability Ac t of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, - 2 - hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, In c. 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 ag ent, without restriction, all of my individually identifiable health information and medical record s regarding any past, present or future medical or mental health condition, including all inform ation 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. I HEREBY REVOKE ALL PRIOR AUTHORIZATIONS, EXCEPT THOSE AUTHORIZATIONS BY INDIVIDUALS, PART NERSHIPS, CORPORATIONS OR OTHER ENTITIES WHO ARE PROVIDING COMPENSATION FOR HEALTH CARE SERVICES, WHICH HAVE BEEN PROVIDED IN MY BEHALF REGARDING THE ABOVE REFERENCED INJURIES. ALL AUTHORIZATIONS BY ANY OTHER PARTNERSHIP, FIRM OR CORPORATION ARE HEREBY REVOKED. THIS AUTHORIZATION REQUESTS ALL OF THE AFOREMENTIONE D MEDICAL INFORMATION PRIOR TO THE DATE OF THIS DOCUMENT'S EXECUTION WITH SAID AUTHORIZATION EXPIRING THREE YEARS FOLLOWING THE DATE OF THIS DOCUMENT’S EXECUTION. Sincerely, ________________________________________