Medical Authorization Form

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION



MY ENTIRE MEDICAL CHART FOR ALL DATES OF SERVICE INCLUDING:

I understand that the information in my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral, psychiatric or mental health services and treatment for alcohol and drug abuse or genetic information. I authorize the release of this information.

This information may be disclosed to and used by the following individual or organization or any of the attorneys or authorized representative thereof for the purpose of legal representation, or to provide copies of my records to opposing parties in litigation, which I have commenced.

MARK YAMPAGLIA LAW PC
Mark E. Yampaglia, Esq.
1 Lincoln Avenue
Rutherford, New Jersey 07070

I understand I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to my insurance company when the law provides my insurer the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date or condition: Resolution of my legal claim or discharge of this attorney. If I fail to specify an expiration date, event or condition, this authorization will expire at the conclusion of the current litigation.

I understand the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosures of my health information, I can contact the HIM director or privacy officer for information.

I understand that this consent shall operate as a complete release of liability to the hospital, medical provider, and to their employees for the release of the information specified above. I have read and understand the terms of this Authorization and I have had an opportunity to ask questions about the use and disclosure of my health information. I hereby, knowingly and voluntarily, authorize the provider of medical services to disclose my health information in the matter described above.


NOTICE OF RECIPIENT OF INFORMATION

Each disclosure made with the patient's consent my be accompanied by the written statement reproduced below. This information has been disclosed to you from records protected by Federal confidentiality rules 42 C.F.R. Part 2. The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent from the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.