Authorization to Obtain Medical Records and Billing Information

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Authorization to Obtain Medical Records and Billing Information for use in a legal proceeding. This authorization sets out the information to be provided and can be revoked at any time by the client.

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This Authorization to Obtain Medical Records and Billing Information will authorize an attorney to obtain a client's medical and billing information. This authorization contains the name of the client, medical provider who possesses the information and purposes for which the information can be used. It also spells out that the client may revoke the authorization at any time. A written Authorization to Obtain Medical Records and Billing Information is necessary in order for an attorney to obtain this needed information.

This Authorization to Obtain Medical Records and Billing Information contains:
  • Authorization/Entity: Entity to whom the authorization is given and the types of information to be provided;
  • Purpose: Sets out that the information is for use in connection with a legal claim or proceeding;
  • Revocation: This authorization can be revoked at any time by the client;
  • Signature: Client/Patient must sign and date this agreement in order for it to be effective.

Protect your rights and property by using our attorney-prepared forms.

This attorney-prepared packet contains:
  1. General Instructions
  2. Authorization to Obtain Medical Records and Billing Information
State Law Compliance: This form complies with the laws of all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
   MEDICAL RECORDS AND BILLING
INFORMATION RELEASE AUTHORIZATION
 
The below described patient hereby authorizes XXX, Attorneys, to obtain, pursuant to HIPAA Rule (Section 164.508), the following information or documents upon the below described terms.
 
1.   The medical provider is authorized to provide any information requested, including all reports, notes, electronic data, lab tests, x-rays, medical imaging, billing information, or any other documents; also, the below described provider is authorized to provide written or oral reports as requested by XXX, Attorneys for the last five (5) years before the accident of _______________.
 
2.   The entity to whom this authorization is directed to is:______________________
 
3.   The above entity can make disclosure of medical information or billing information to XXX, Attorneys. or any employee or agent of said law firm.  This does not allow these lawyers to speak with the treating medical providers.
 
4.   The purpose of this disclosure is to obtain information for use by my attorneys in connection with a legal claim or proceeding.  The expiration date of this authorization is two (2) years from the date of the signature below.
 
5.   The undersigned understands that he or she may revoke this authorization at any time, without exceptions, by sending a written request to XXX, Attorneys and/or to the medical provider.
 
6.   The undersigned understands that the information obtained by XXX, Attorneys pursuant to this authorization may be used by them for purposes of any legal claims being presented by XXX, Attorneys on behalf of the below described individual.  The undersigned understands that if medical records are obtained by XXX, Attorneys, that said records or copies may be provided to those entities, or their representatives, against whom legal claims are being presented; and said records will be subject to examination by XXX, Attorneys and those employees or agents hired by XXX, Attorneys to examine said documents for purposes of legal claims or proceedings.  If said information is provided to insurance adjusters, defense lawyers, or others against whom the legal proceeding or claim is presented, said disclosure will not be subject to the HIPAA Rule.
 
7.   I may revoke this authorization at any time in writing, but if I do, it will not have any affect on my actions taken prior to receiving the revocation.  Further details may be found in the Notice of Privacy Practices.
 
8.   I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.
 
DATED this _____ day of ____________________, 20______.                                            
_________________________________________
Client/Patient
 
Number of Pages2
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28067
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
   MEDICAL RECORDS AND BILLING
INFORMATION RELEASE AUTHORIZATION
 
The below described patient hereby authorizes XXX, Attorneys, to obtain, pursuant to HIPAA Rule (Section 164.508), the following information or documents upon the below described terms.
 
1.   The medical provider is authorized to provide any information requested, including all reports, notes, electronic data, lab tests, x-rays, medical imaging, billing information, or any other documents; also, the below described provider is authorized to provide written or oral reports as requested by XXX, Attorneys for the last five (5) years before the accident of _______________.
 
2.   The entity to whom this authorization is directed to is:______________________
 
3.   The above entity can make disclosure of medical information or billing information to XXX, Attorneys. or any employee or agent of said law firm.  This does not allow these lawyers to speak with the treating medical providers.
 
4.   The purpose of this disclosure is to obtain information for use by my attorneys in connection with a legal claim or proceeding.  The expiration date of this authorization is two (2) years from the date of the signature below.
 
5.   The undersigned understands that he or she may revoke this authorization at any time, without exceptions, by sending a written request to XXX, Attorneys and/or to the medical provider.
 
6.   The undersigned understands that the information obtained by XXX, Attorneys pursuant to this authorization may be used by them for purposes of any legal claims being presented by XXX, Attorneys on behalf of the below described individual.  The undersigned understands that if medical records are obtained by XXX, Attorneys, that said records or copies may be provided to those entities, or their representatives, against whom legal claims are being presented; and said records will be subject to examination by XXX, Attorneys and those employees or agents hired by XXX, Attorneys to examine said documents for purposes of legal claims or proceedings.  If said information is provided to insurance adjusters, defense lawyers, or others against whom the legal proceeding or claim is presented, said disclosure will not be subject to the HIPAA Rule.
 
7.   I may revoke this authorization at any time in writing, but if I do, it will not have any affect on my actions taken prior to receiving the revocation.  Further details may be found in the Notice of Privacy Practices.
 
8.   I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.
 
DATED this _____ day of ____________________, 20______.                                            
_________________________________________
Client/Patient
 
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