AUTHORIZATION FOR USE & DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE AND PROTECTED HEALTH INFORMATION (“HEALTH INFORMATION”)
1. PATIENT IDENTIFICATION
PRINTED NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
2. PATIENT ADDRESSES
ADDRESS (Current Residence):
CITY: STATE: ZIP:
ADDRESS (Time of Treatment/Prescription):
CITY: ____________________________ STATE: ______ ZIP:___________________________
3. PERSONS/ORGANIZATIONS AUTHORIZED TO DISCLOSE HEALTH INFORMATION: (hereinafter referred to as “Custodian Of Records”):
4. PERIODS OF HEALTH CARE/HEALTH INFORMATION/ACADEMIC INFORMATION TO BE DISCLOSED
By signing, I authorize the Custodian of Records to release my medical or billing records containing information in reference to: Communicable and Non-Communicable Diseases, and/or Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records.
Date (From): _____________ Date (To): _________________
Date (From): _____________ Date (To): _________________
HOSPITAL MEDICAL RECORDS:
___Complete Inpatient and Outpatient Health Record
___Emergency Room Record
___History & Physical Exam
___Discharge Summary
___Consultation Reports
___Progress Notes
___Laboratory Test Results
___Radiology Reports
___Radiology Studies (Films & Images) to Match Attached Reports
___Operative Reports
___Pathology Reports
___Pathology Slides
___Photographs, Videotapes
___Abstract of Health Record (All Transcribed Physician Reports & Test Results)
MEDICAL RECORDS:
___Complete Emergency Medical Transport & Health Record
___Complete Autopsy Report, Autopsy Photographs, & Toxicology Report
___Complete Health Record from Physician’s Office* or Clinic* or Chiropractor* or Acupuncturist
___Complete Pharmacy/Prescription Record
___Complete Rehabilitation/Physical/Occupational/Recreational/Speech Therapy Record*
___Complete Psychiatric, Psychological, Licensed Clinical Social Worker, Mental Health Counselor/Therapist Record and associated Testing*
___Complete Home Health/Nursing Record*
___Complete Nursing Home Record*
___Complete Funeral Home Record
___Complete Durable Medical Equipment Record/Medical Supply Record*
___Complete Prosthetic Equipment & Fitting Record*
___Complete Dental Record*
___Radiology Reports*
___Radiology Studies (Films & Images)
___Laboratory Test Results*
___Pathology Reports*
___Pathology Slides
___Photographs, Videotapes, Digital Images
___Other
• Including records/documents received from any other health care providers, therapists, or counselors.
BILLING RECORDS:
___Complete Billing Record including an Itemized Statement
5. TO WHOM AND WHERE TO SEND DISCLOSED HEALTH INFORMATION:
I authorize the disclosure and use of the Health Information described above to the following person(s) or organization(s):
SEND INFORMATION TO:
Watts Guerra LLC
AS AGENT FOR 5726 W Hausman Rd Ste 119
San Antonio, TX 78249
866.529.9100
6. PURPOSE OF DISCLOSURE/USE:
CIVIL LITIGATION
7. RE-DISCLOSURE:
I understand the information disclosed by this Authorization may be subject to re-disclosure by the recipients and no longer be protected by the Health Insurance Portability and Accountability Act of 1996. The facilities, their employees and officers are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
8. LIMIT & RIGHT TO REVOKE AUTHORIZATION:
Except to the extent that action has already been taken in reliance on this Authorization, I understand this Authorization is voluntary and that I may revoke it at any time by submitting a notice in writing to the Custodian of Records or organization(s) providing the Protected Health Information. Unless revoked this Authorization will expire on the following date or event: upon completion of pending civil litigation.
Expiration date/event is further defined as resolution of the claim asserted or at the conclusion of any litigation instituted in connection with the subject matter of pending civil litigation and/or of the Notice of the Health Care Claim. Treatment, payment, enrollment in a health plan, or eligibility for health insurance benefits may not be conditioned on my signing this authorization.
9. The office of WATTS GUERRA, is authorized to discuss with any health care provider, therapist, individual, fiduciary, agent, or other person any evidence, testimony or fact deemed by said attorneys to be material, and said attorneys and their agents are authorized to examine, inspect, copy, and/or inquire of any person, firm, corporation, institution or agency thereof concerning or relating to any evidence, documents, reports, and/or records. All such persons are requested to freely cooperate with said attorneys or their agents.
10. The Custodian of Records is released from any legal responsibility for the disclosure of the above stated Health Information to the extent indicated and authorized herein.
11. A facsimile, photostatic, carbon or other copies of this Authorization are intended and shall be treated as an original.
12. I understand that the health information described above may be transmitted electronically and may be redisclosed electronically by WATTS GUERRA.
13. RIGHTS & SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE REQUESTING DISCLOSURE:
I understand that I do not have to sign this Authorization and that my treatment or payment for services will not be denied if I do not sign this form unless specified above under Purpose of Request. I can inspect or copy the Health Information to be used or disclosed. I may see and receive a copy of this Authorization. I authorize the Custodian of Records to disclose the Health Information specified above. The information I am requesting may be sent by U.S. mail service, expedited mail services (such as Federal Express, Lone Star, etc.) and/or electronic facsimile in accordance with the provider’s facsimile policy.
**If you are signing as a PERSONAL REPRESENATIVE of another person, you MUST provide a description of your authority to act for the other person (for example, a Power of Attorney), and a copy of the document, if any, that authorizes you to act as the patient’s personal representative.
