HIPAA Authorization for Attorney Access to Records
Patient Name:
Date of Birth:
Attorney Name and Firm:
Attorney Address:
Healthcare Provider(s) Authorized to Release Records:
Information to be Disclosed:
All medical records
Billing records
Other (specify):
Purpose of Disclosure:
Authorization Expiration Date or Event:
Patient Rights & Acknowledgment:
I understand that I may revoke this authorization at any time in writing.
I understand that the information disclosed may be subject to re-disclosure and no longer protected by HIPAA.
I have the right to a copy of this authorization.
Signature of Patient or Personal Representative:
Date:
If Personal Representative, describe authority: