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New Jersey HIPAA Release Form

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57 views2 pages

New Jersey HIPAA Release Form

Find

Uploaded by

florose59
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT

INFORMATION PURSUANT TO 45 CFR 164.508

TO:
Name of Healthcare Provider/Physician/Facility/Medicare Contractor

Street Address

City, State and Zip Code

RE: Patient Name:

Date of Birth: _ _ _ _ _ _ _ _ Social Security Number: _ _ _ _ _ _ _ _ _ _


I authorize and request the disclosure of all protected information for the purpose of
review and evaluation in connection with a legal claim. I expressly request that the designated
record custodian of all covered entities under HIPAA identified above disclose full and complete
protected medical information including the following:

D All medical records, meaning every page in my record, including but not limited to:
office notes, face sheets, history and physical, consultation notes, inpatient, outpatient
and emergency room treatment, all clinical charts, r ports, order sheets, progress notes,
nurse's notes, social worker records, clinic records, treatment plans, admission records,
discharge summaries, requests for and reports of consultations, documents,
correspondence, test results, statements, questionnaires/histories, correspondence,
photographs, videotapes, telephone messages, and records received by other medical
providers.

D All physical, occupational and rehab requests, consultations and progress notes.

D All disability, Medicaid or Medicare records including claim forms and record of denial
of benefits.

D All employment, personnel or wage records.


All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records
D and specimens; radiology records and films including CT scan, MRI, MRA, EMG,
bone scan, myleogram; nerve conduction study, echocardiogram and cardiac
catheterization results, videos/CDs/films/reels and reports.

D All pharmacy/prescription records including NDC numbers and drug information


handouts/monographs.
All billing records including all statements, insurance claim forms, itemized bills, and
D records of billing to third party payers and payment or denial of benefits for the period
_____ to _ _ _ _ _ _
I understand the information to be released or disclosed may include information relating to
sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human

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immunodeficiency virus (HI ), and alcohol and drug abuse. I authorize the release or disclosure
of this type of information.
This protected health information is disclosed for the following purposes: _ _ _ _ _ _ _ _

This authorization is given in compliance with the federal consent requirements for release of
alcohol or substance abuse records of 2 CFR 2. , the restrictions of which have been
specifically considered and expressly waived.
ou are authorized to release the above records to the following representatives of defendants in
the above entitled matter who have agreed to pay reasonable charges made by you to supply
copies of such records:

Name of Representative

Representative Capacity (e.g. attorney, records requestor, agent, etc.)

Street Address

City, State and Zip Code

I understand the following: See C F R §164.S08(c)(2)(i-iii)


a. I have a right to revoke this authorization in writing at any time, except to the extent
information has been released in reliance upon this authorization.
b. The information released in response to this authorization may be re disclosed to other
parties.
c. My treatment or payment for my treatment cannot be conditioned on the signing of this
authorization.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records
requested herein. This authorization shall be in force and effect until two years from date of
execution at which time this authorization expires.

Signature of Patient or egally Authorized Representative Date


(See 4SCFR § 164.S0S(c)(l)(vi))

Name and Relationship of egally Authorized Representative to Patient


(See 4SCFR § 164.508(c )( 1)(iv))

itness Signature Date

Page 2 of 2

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