Free Sentencing Memo (Supporting Documents) - District Court of Arizona - Arizona

AUTHORIZATION FOR RELEASE OF PROTECTED AND CONFIDENTIAL
MEDICAL INFORMATION AND RECORDS
This release is intended to comply with the provisions of the
Health Insurance Portability and Accountability Act (HIPAA)
To: gt Bassam Hadj
From: Tgmyg ,1 , Mgyjagh
Authorization for Release of Medical and Protected Health Infomation (“PHI”) Records to legal counsel, the
Law Office of Tonya J. McMath: By this release, or a photocopy of facsimile transmission thereoij hereby authorize
and request you to release to the Law Oliice of Tonya J. McMath, its investigators and assistants, any and all medical
files, documents, infomation and/or records, including PHI, relating to myself.
For the purpose of this authorization, the terms "tiles, documents. information and/or records" are to be broadly
construed and include without limitation the original or copy thereotj regardless of origin or location, or any book,
pamphlet, periodical. letter, memorandum, telegram, report, record, study, handwritten notes, working paper, charts,
paper, graph, calendar, index, tape, data sheet, or data processing card, or any other written, recorded, transcribed,
punched, taped, filmed, or graphic item, however produced or reproduced, which is in your possession, or in the
possession of any of your agents, contractors or employees, or any person or entity to which you have access.
Use of Information: Any information provided pursuant to this release is to be used in the legal proceedings of Paul
K. Bggan , including related legal actions. I understand that use ofthe material in those proceedings may involve
disclosure of PHI to individuals or entities that are not covered by the Health Insurance Portability and Accountability
Act, and in that case, the material may no longer be protected by federal confidentiality law.
Expiration: This release will expire upon the conclusion ofthe legal proceedings described in the paragraph above,
unless revoked by me at an earlier time.
Revocation: I understand I have the right to revoke this authorization at any time. My revocation must be in writing.
conform to the requirements described in the hospital/medical center Notice of Private Practices, and be provided to the
covered entity. I understand that my revocation will be effective upon its receipt by the person(s) I have authorized to
release the material. but will not be effective to the extent that such persons have previously acted in accordance with
this Authorization and in reliance thereon.
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C y eceiv : I Qderpand I have a right to receive a signed copy ofthis Au ti ch is completely filled out.
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Social Security Number Witness ;Y_ B rxfan
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Case 2:O3—cr—O1269-NVW Document 250-3 Filed O3/30/2006 Page 1 of 2

Addendum to Authorization for Release of Protected and Conlidential Medical
Information and Records Pursuant to the Health Insurance
Portability and Accountability Act of I996 (HTPAA)
l, Paul K. Bryan , Lmderstand that the Law Oflice of Tonya J. McMath, its investigators and
assistants, may use my signed Authorization for Release of Protected and Confidential Medical Information and Records,
to obtain any and all medical tiles, documents, information and/or records, including Protected Health Infomation
("PHl") from any number of diH`erent medical institutions and providers. lt is my intention to allow the Law Office of
Tonya J. McMath to obtain all medical iiles, documents and/or records, including PHI, from any institution, provider
or insurer that possess such information. /Z/D
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Name si , ature ' \
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Social Security Number Witness .·§${...
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Date irth late igned
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Case 2:03-cr—O1269-NVW Document 250-3 Filed O3/30/2006 Page 2 of 2

Case 2:03-cr-01269-NVW

Document 250-3

Filed 03/30/2006

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Case 2:03-cr-01269-NVW

Document 250-3

Filed 03/30/2006

Page 2 of 2