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HIPPA Original

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Steven Obryan
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26 views1 page

HIPPA Original

Uploaded by

Steven Obryan
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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MEDICAL PROVIDER: ________ _______________________

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA Form)


Patient’s PRINTED Name: Birth date: Social Security No:

Address: Home Phone Number: Work Phone Number: ( )

I hereby authorize ___________________________________________________________________________ to disclose records


obtained in the course of my evaluation and/or treatment to: (Name and address of person or organization to which disclosure is to be made)
Name: Lovins | Trosclair, PLLC Address: 12700 Park Central Drive
Suite 520
Dallas, Texas 75251
Phone Number: 214.484.1930 Fax Number: 214.972.1047
Type of Access Requested: Copies of Record Inspection of records
Medical Records: (Entire Record or Selected Portions of PHI as marked)
Description: Date(s) Description: Date(s) Description: Dates(s)
Entire Records [ ] Lab [ ] Face Sheet
(or Portions): [ ] Imaging/Radiology [ ] Other_______________
[ ] Discharge Summary [ ] Nursing Notes
[ ] Emergency Room Records [ ] Medication Record Billing Records*
[ ] History and Physical [ ] Psychological Record [X] Detailed Bill
[ ] Consult Report(s) [ ] Psychiatric Record(s) [ ] UB92
[ ] Operative Report(s) [ ] Progress Notes
[ ] Rehab Services [ ] Physician Orders
Type:_________________ [ ] Pathology Report
__________(Initials) I DO or I DO NOT consent to release of information relating to psychiatric or psychological testing or
treatment, biofeedback training, alcohol and/or drug abuse diagnosis, prognosis and treatment and/or HIV (AIDS) testing and/or
results, or such disclosure shall be limited to the following specific types of information: None

List the purpose(s) for the release or disclosure of Protected Health Information: For the proper handling of a tort claim and a
potential lawsuit filed on my behalf by the requesting party

This consent is subject to written revocation by the undersigned at any time except to the extent that action has been taken and if
not earlier revoked. To revoke this authorization, contact the Medical Provider’s Medical Records Department for assistance.
This consent shall become invalid and expire from the date of signature in the following manner: Expiration date: 01/01/25
or Expiration Event: Settlement or court award or None: or Define:
I understand that:
1. Information disclosed by this authorization may be re-disclosed by the recipient of your PHI. Such re-disclosure will no longer be
protected by this authorization.
2. I have the right to receive a copy of this authorization. Copy of the authorization received. (Initials)
3. A copy or facsimile (fax) of this authorization is as valid as the original.
4. My healthcare and the payment of my healthcare will not be affected if I refuse to sign this authorization.
I hereby release the Medical Provider named above from any and all legal liability and injuries that arise from the release of this
information as to the party named above. The information that I am requesting may be sent by U.S. mail service and/or electronic
facsimile in accordance with the Medical Provider’s facsimile (fax) policy.
I have read the above or have had it read to me and I authorize the disclosure of the Protected Health Information as stated.

SIGNED: DATE:
(Signature of Patient/Legal Guardian or Representative)
If signed by other than patient, indicate relationship:

Witness: DATE:
(If signed by other than patient)
To the Party Receiving this Information: This information has been disclosed to you from the records whose confidentiality may be protected by
state and/or federal law. Certain regulations prohibit you from further disclosure of it without the specific written consent of the person to whom it
pertains, or otherwise as permitted by such law and regulations. A general authorization for the release of such medical or other information is not
sufficient for this purpose. Fees will be charged for the release of information in accordance with the law.

Form HIPAA

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