Free Form Friday: HIPAA Medical Authorization Form

free samples

Today’s free form is a HIPAA Medical Authorization that our Personal Injury Attorneys have clients sign in order to obtain our clients’ medical records. We have drafted this form to have all of the information that the most common North Carolina hospitals require. If you are looking to obtain someone’s medical records for a legal case (or other use), have that person sign a form like the one below and you should be able to order that person’s medical records without too much trouble.

Authorization for Release of Medical Information

Patient Name: ____________________________________________________
Patient Address: ___________________________________________________
Patient Date of Birth: ________________________________________________
Patient Social Security #: ______________________________________________
Patient Phone Number: _______________________________________________
Date(s) of Treatment: ________________________________________________

Medical Facilities Authorized to Release Information:







Authorized recipient of Information: _______________________________________

Expiration of this authorization: __________________________________________

Information to be released and disclosed:

All information of any kind on file concerning me including, but not limited to, Medical Bills, Patient Billing Records, Pictures/Photos, Clinic Notes, Summary Health Information (all dictated reports), History and Physical, Discharge Summary, Operative Report, Entire Record, Laboratory Reports, Radiology Reports, Emergency Department Reports, Physical Therapy/Occupational Therapy Notes, Patient Discharge Instructions, X-ray Films, Electronic Medical Records, Consultations, Emergency Room Record, EDG/ECG Tests, Therapy Notes, Progress Notes, Medication Records, Doctor’s Orders, Nurse’s Notes, Treatment Plans, Commitment Papers, Pathology Reports, MAR, Urgent Care Center Notes, etc.

Purpose or Need for release or disclosure: _____________________________.

I understand I may refuse to sign this authorization, and that my refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or my eligibility for health benefits. I acknowledge that the information disclosed pursuant to this information may be subject to re-disclosure by the recipient and no longer will be protected by Federal Law. I understand I have the right to revoke this authorization by written notice to the healthcare providers listed on this authorization. I understand that actions taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually transmitted disease, and acquired immunodeficiency syndrome and human immunodeficiency virus. I understand and agree that there may be costs associated with this request in compliance with State or Federal copying laws.

_______________________ _______________
Patient Signature                                Date


I certify that ______________________________ personally appeared before me this day, acknowledging to me that he or she voluntarily signed the foregoing authorization for release of medical information.

Witness my hand and official stamp or seal, this the _________ day of ___________, _______.

Notary Public