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La 5382

This document is a medical authorization allowing the examination and reproduction of medical records, including hospital records, x-rays, and laboratory reports. It grants authority to the individual or their delegate to access and receive reports related to their medical history and treatment, in compliance with HIPAA regulations. The authorization has no expiration date unless revoked in writing.

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10 views2 pages

La 5382

This document is a medical authorization allowing the examination and reproduction of medical records, including hospital records, x-rays, and laboratory reports. It grants authority to the individual or their delegate to access and receive reports related to their medical history and treatment, in compliance with HIPAA regulations. The authorization has no expiration date unless revoked in writing.

Uploaded by

acadianajd
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MEDICAL AUTHORIZATION

TO: _______________
_______________
_______________
___________, LA ________

RE: _______________
Medical Records

You are hereby authorized and directed to permit the examination of and the copying or
reproduction in any manner, whether mechanical, photographic, or otherwise, by my me or such
other person as I may authorize, all or any portions desired by me of the following:

a. Hospital records, x-rays, x-ray readings and reports, laboratory records and
reports, all tests of any type and character, and reports pertaining to
hospitalization, history, condition, treatment, diagnosis, prognosis, etiology or
expenses;

b. Medical records, including patient's record cards, x-rays, x-ray readings and
reports, laboratory records and reports of all tests of any type and character, and
reports thereof, statements of charges, and any and all of my records pertaining to
medical care, history, condition, treatment, diagnosis, prognosis, etiology or
expenses.

You are further authorized and directed to furnish oral and written reports to me, or my
delegate, as requested by me for any of the foregoing matters.

I also authorize my attorney(s) or their delegate to photograph my person while I am


present in any hospital.

HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights
regarding the use and disclosure of my individually identifiable health information or other
medical records. This release authority applies to any information governed by the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR
160 through 164. I authorize any physician, health care professional, dentist, health plan,
hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance
company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has
provided treatment or services to me, or that has paid for or is seeking payment from me for
such services, to give, disclose and release to my agent, without restriction, all of my
individually identifiable health information and medical records regarding any past, present or
future medical or mental health condition, including all information relating to the diagnosis of
HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The
authority given my agent shall supersede any other agreement that I may have made with my
health care providers to restrict access to or disclosure of my individually identifiable health
information. The authority given my agent has no expiration date and shall expire only in the
event that I revoke the authority in writing and deliver it to my health care provider.

________________________________
_______________

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