Sample hipaa release

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 240-241

Form 10 ERISA Disability Claims and Litigation A-222

FORM 10 SAMPLE HIPAA RELEASE

AUTHORIZATION FOR THE RELEASE

AND/OR DISCUSSION OF MEDICAL RECORDS

PATIENT INFORMATION

Patient Name: ___________________

Social Security Number: ___________________

Birth Date: ___________________

AUTHORIZATION

1. I, hereby authorize any health plan, physician, health care professional, hospi-

tal, clinic, laboratory, pharmacy, medical facility, or other health care provider.

2. To release to: LAW FIRM, ADDRESS

• In emergency, release via fax

• In emergency, do not release via FAX

3. The following information:

• Complete Record

• Outpatient Care Record

• Inpatient Care Record

• Test Results

• Laboratory Results

• Disability Information

4. If my record contains the following information, it is also released if INDI-

CATED in boxes below:

• Substance Abuse

• Mental Health Treatment

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5. The Information Release is for the purpose of: My claim for long term and/or

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SIGNATURE

I have carefully read and understand the above information, and do herein

consent to its disclosure. I am aware that information regarding my medical

condition will be released to those persons or organizations named above.