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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)
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Street Address:
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City, State and Zip Code:
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RE:
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Patient Name: *
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Date of Birth: *
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Social Security Number:
000-00-0000
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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:
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, reports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, request for and reports of consultation, documents, correspondence, test results, statements, questionnaires/histories, correspondence, photographs, videotapes, telephone messages, and records received by other medical providers. *
All physical, occupational and rehab requests, consultations and progress notes. *
All disability, Medicaid or Medicare records including claim forms and record of denial of benefits. *
All employment, personnel or wage records. *
All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records 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. *
All pharmacy/prescription records including NDC numbers and drug information handouts/monographs. *
All billing records including all statements, insurance claims forms, itemized bills, and records of billing to third party payers and payment or denial of benefits forthe period *
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ACKNOWLEDGMENT
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release of disclosure of this type of information.

This protected health information is disclosed to my attorney to aid in the recovery of damages resulting from a personal injury.

This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.

You 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:
This authorization appoints BAUSCH LAW GROUP to represent patient.

Records are to be mailed to: BAUSCH LAW GROUP 1247 7th Street, Suite 301, Santa Monica, CA 90401
I understand the following: CFR §164.508(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.

d. I have a right to receive a copy of the authorization. I also have a right to receive a copy of my medical records obtained.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records request 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
In accordance with 45 CFR § 164.508(c)(1)(vi). / If filled out electronically, put your full name
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Date:
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Name and Relationship of Legally Authorized Representative to Patient:
In accordance with 45 CFR § 164.508(c)(1)(iv)
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Date:
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Witness Signature:
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