This form grants authority to the attorney to obtain the client's medical records from the client's medical provider.
Authorization For Medical Records Release
State:
Multi-State
Control #:
US-PI-0012
Format:
Word;
Rich Text
Instant download
Description
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How to fill out Limited Authorization To Inspect And Copy Medical Records?
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FAQ
Under the HIPAA Privacy Rule, when a release of information is intended for purposes other than medical treatment, healthcare operations, or payment, you'll need to sign an authorization for ROI. The healthcare organization releasing your information will check that the authorization is valid during the ROI process.
What Information Must a HIPAA Authorization Contain to be Valid? A description of the specific information to be used or disclosed. The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure.
compliant HIPAA release form must, at the very least, contain the following information: A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.
Generally, an authorization provides the authority for a doctor's release of PHI for specified purposes, which are generally other than treatment, payment, or healthcare operations, or, to disclose protected health information to a third party specified by the individual.
I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested (e.g., medical-history form you filled out; physician and nurses' notes; test results; consultations with specialists; referrals).]