AUTHORIZATION FOR THE USE AND DISCLOSURE
OF MY PROTECTED HEALTH INFORMATION AND
MEDICAL RECORDS OF ALL KINDS BY **YOUR NAME**

I, **YOUR NAME**, HEREBY AUTHORIZE AND DIRECT ALL OF MY PHYSICIANS AND HEALTH CARE PROVIDERS, NOW AND IN THE FUTURE, INCLUDING, BUT NOT LIMITED TO, **NAMES OF PHYSICIANS** AND ALL HOSPITALS AND OTHER HEALTH CARE PROVIDERS TO USE OR DISCLOSE MY PROTECTED HEALTH INFORMATION AS DESCRIBED HEREIN.

I understand that once disclosed, the information I authorize to be disclosed by said person/facility may be disclosed to others and will no longer be protected by state and federal regulations.

I hereby authorize the release of my protected medical records and related information to all of my medical care beginning on (**BEGINNING DATE**) and continuing through date hereof and hereafter until (**ENDING DATE, IF ANY**) to the following individuals: **LIST ALL RECIPIENTS AND ADDRESSES**.

This authorization includes not only my protected health information as set forth herein, but also as may be requested by said law firm in the future. I ALSO AUTHORIZE THAT THE SAME RECORDS BE MADE AVAILABLE AND DISCLOSED IMMEDIATELY TO MY AGENT APPOINTED BY MY HEALTH CARE POWER OF ATTORNEY.

The purpose of these Disclosures is to provide my named recipients with information about my health care treatment, the assessment of my medical status regarding my future living conditions, and the protection of my rights. Disclosures of my treatment shall continue until (**ENDING DATE, IF ANY**) or unless this Authorization is revoked by me in writing, and the revocation is delivered to each health care provider. In addition, I authorize all named recipients to secure updated information from the above named persons/entities/facilities and all other health care providers regarding my prior and ongoing care and treatment. I direct that my entire Medical Record and all of my protected health records and medical information be provided including, but not limited to, History and Physical; Admission and Discharge Summaries; Operative Reports; Progress Notes and Nursing Notes; Laboratory Reports; Radiology Reports; Immunization Records; Billing Summaries; Consultation Reports; Pathology Reports; Psychological and Psychiatric Assessments; and Medications.

I understand that in the event I was treated for drug or alcohol abuse, psychiatric condition, communicable diseases including HIV/AIDS, this information will be included as part of my medical record to the above-named named recipients. (Initials___________)

I understand that the above person/entity/facility may not condition treatment, payment, enrollment or eligibility for benefits on signing this authorization.

This authorization is subject to cancellation/revocation at any time, by me or my legally qualified representative; provided, however, that cancellation shall be made in writing and delivered to the person/entity/facility except the extent that this authorization has already been acted on prior to receipt of my request to cancel the authorization, or, if the authorization was given to release records to my insurance company in order to obtain insurance coverage. (Initials______________)

I do not wish this authorization to automatically expire in 90 days, and direct that it remain in effect until **ENDING DATE, IF ANY** unless and until revocation or cancellation is delivered to the recipient hereof. A copy of this document shall have the same effect as an original.

_____________________________________________ _______________________________
Signature of Individual or Legally Qualified Representative Date
Social Security Number: _______________________
DOB:**DATE OF BIRTH**
_____________________________________________
Relationship of Legally Qualified Representative
Please Address Correspondence to
_________________
_________________
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