ABOUT THIS FORM:
In order to obtain a client’s medical treatment records, lawyers need written authorization from the client. This is a standard authorization form in which the client authorizes the lawyer to obtain and use their medial records. This form is in compliance with the current HIPPA requirements.
Authorization to Use or Disclose Health Information in Compliance with the Health Insurance Portability and Accountability Act (HIPPA)
Patient Name: JANE DOE
(1) Above-named PATIENT hereby authorizes the use or disclosure of his/her health information as described below.
(2) The following individual(s) or organization(s) are authorized to make the disclosure:
(3) The type of information to be used or disclosed is as follows: COMPLETE MEDICAL RECORDS AND ITEMIZED ACCOUNT STATEMENTS.
(4) I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
(5) PLEASE SEND THE INFORMATION REQUESTED ABOVE DIRECTLY TO MY ATTORNEYS: Smith & Smith, LLP, 101 Pratt Street, Suite 2100, Baltimore, MD 21201, 410-555-5555.
(6) The information for which I’m authorizing disclosure will be used for my personal injury litigation.
(7) I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
(8) This authorization will expire one year from the date on which it was signed.
(9) I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations.
(10) I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.
SIGNATURE OF PATIENT (or Legal Representative):
FAQS: Client Medical Records Authorizations Under HIPPA
What is required in a records authorization form under HIPPA?
To be in full compliance with HIPPA, a medical records authorization form must contain the following:
(1) A brief description of the records/health information to be used/disclosed.
(2) The purpose that the health information is being used for (e.g., personal injury lawsuit).
(3) The name of the person or company that is authorized to obtain the information.
(4) An expiration date for when the authorization will terminate.
(5) Patient signature.
Is there an "official" HIPPA authorization form?
No. HIPPA sets forth certain requirements that must be contained in a medical authorization form, but the law itself does not adopt an official or universal HIPPA authorization form.
What is an authorization to release medical records?
An authorization to release medical records is something in writing that you sign which gives your doctors or healthcare providers permission to release copies of your medical records and information to a designated third party. In personal injury lawsuits, medical authorizations are used to enable your attorney to collect medical records related to your lawsuit.