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Generic Authorization Medical Release Form


Generic Authorization Medical Release Form
Generic Authorization Medical Release Form
HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT
INFORMATION PURSUANT TO 45 CFR 164.508
TO: ______________________________________________________________________
Name of Healthcare Provider/Physician/Facility/Medicare Contractor
______________________________________________________________________
Street Address
______________________________________________________________________
City, State and Zip Code
RE: Patient Name: _________________________________________________________
Date of Birth: _________________ Social Security Number: ____________________
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, r ports, order sheets, progress notes, nurse's notes, social worker
records, clinic records, treatment plans, admission records, discharge summaries, requests for
and reports of consultations, 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.
Generic Authorization Medical Release Form
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