Chapter 1 - FORM 1-13 : AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS UNDER HIPAA

• Jurisdiction: Colorado

Form 1-13: Authorization for Release of Medical Records Under HIPAA

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

To: [health care provider's name]
[health care provider's address]

Patient Name: __________ Date of Birth: __________

Regarding: __________ v. __________, Civil Action File/Case No: ___, ___ Court, State of ___ ("the Lawsuit")

Information to be Used or Disclosed:

I authorize any physician, hospital, health care provider, health facility, insurance carrier, and governmental or private agency, including any state workers' compensation agency, and each of them together with their respective employees and/or agents, to disclose my "protected health information" to [attorney's name and address], as specified in this authorization and set forth in privacy regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA Privacy Rule).

I understand that my protected health information includes any and all medical records, written medical opinions, original x-rays, insurance documents, papers, notes and histories, pathology, tissue samples, cytology, blocks, slides, or other pathology specimens, or any other documents, records or papers concerning any past medical history and/or treatment, examinations, periods of hospitalizations or confinement, diagnoses, or any other information pertaining to and concerning my physical or mental condition and treatment or billing/payment information relating thereto, for the past 20 years only, i.e., protected health information up to and including 20 years before the date of this authorization. I understand "protected health information" also includes records disclosed to my health care providers by health care providers and facilities who previously provided treatment to me. I understand "protected health information" may also include information and records protected under federal law (such as alcohol and drug abuse treatment information) and/or protected under state law (such as mental health treatment or AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus). I specifically authorize the disclosure of any and all protected health information, opinions, records, medical records, medical history, consultation, prescription or treatment relating to my physical or mental health and relating to any referral, diagnosis, or treatment for alcohol or drug use. I also specifically authorize the disclosure of any and all papers concerning any...