Free Interrogatories Propounded - District Court of Delaware - Delaware

Case 1:05-cv-00032-SLR

Document 10-2

Filed 04/22/2005

Page 1 of 1

HIPAA COMPLIANT AUTHORIZATION FORM PURSUANT TO 45 CFR 164.508 Name or specific identification of the person(s), or class of persons, authorized to make the requested disclosure:

Patient Name: Christopher Page, Jr. Date of Birth: Address:

AKA: Social Security Number:

I authorize the disclosure of all protected medical information for the purpose of review and evaluation in connection with a legal claim. I expressly request that all covered entities under HIPAA identified above disclose full and complete protected medical information spanning the time period of first treatment to present including the following: · All medical records, including inpatient, outpatient and emergency room treatment, all clinical charts, reports, documents, correspondence, test results, statements, questionnaires/histories, office and doctor's handwritten notes, and records received by other physicians. · All autopsy, laboratory, histology, cytology, pathology, radiology, CT Scan, MRI, echocardiogram and cardiac catheterization reports. · All radiology films, mammograms, myelograms, CT scans, photographs, bone scans, pathology/ cytology/ histology/ autopsy/ immunohistochemistry specimens, cardiac catheterization videos/CDs/films/reels, and echocardiogram videos. · All pharmacy/prescription records including NDC numbers and drug information handouts/monographs. · All billing records including all statements, itemized bills, and insurance records. Information about alcohol/substance abuse and HIV/AIDS may be disclosed as follows: (check all that apply) ____Yes, disclose HIV/AIDS information. OR X No, do NOT disclose HIV/AIDS information. __X_Yes, disclose alcohol/substance abuse information OR No, do NOT disclose alcohol/substance abuse information. I authorize you to release the protected health information to: Roger D. Landon, Murphy Spadaro & Landon, 1011 Centre Road, Suite 210, Wilmington, DE 19805, Tel: 302-472-8112, Fax: 302-225-3673. This authorization does not apply to psychotherapy notes, psychiatric or psychological records. I acknowledge the right to revoke this authorization by writing to Roger D. Landon at Murphy Spadaro & Landon at the above referenced address. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I acknowledge the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer be protected under 45 CFR 164.508. I understand that the covered entity to whom this authorization is directed may not condition treatment, payment, enrollment or eligibility benefits on whether or not I sign the authorization. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records herein. This authorization expires two years from the date below. Signature: ____________________________________________ Date: ______________________ Relationship to the person who is the subject of the records: Self: X Other: Describe authority

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