Patient's Printed Name:  


Contact Phone Number:  

I hereby authorize the use/disclosure of health information about me as described below. I hereby authorize 

to disclose records obtained in the course of my evaluation and/or treatment to the class of person presenting this release to you as detailed below via:  


The information will1 be used/disclosed for discovery purposed and/or as evidence in the lawsuit styled:

Records and/or slides, samples, films and/or images obtained by the requesting part may be forwarded to testifying and/or consulting experts of the requesting party consistent to the purposes of the lawsuit referenced herein. The Authorizing party will have no right to the disclosure of the consulting experts in this mailer outside of the scope of the lawsuit referenced herein

TYPE OF ACCESS REQUESTED: Copies of Records and pathology slides, tissue samples, x-ray films/films of any kind, computer stored images and any test or procedure results (however maintained) for all the time periods past until two years from the date of this authorization.

DESCRIPTION OF RECORDS OR SLIDES/SAMPLES/FILMS/IMAGES REQUESTED: ENTIRE RECORD, including, but the following categories of records: Discharge Summary. Emergency Room Records, History and Physical Records, Consult Report(s). Operative Report(s), Rehab Services, Laboratory Reports, Imaging/Radiology, Nursing notes, Medication Record, Psychological Record, Psychiatric Records(s). Progress Notes. Physician Orders, Pathology Reports(s), Cardiopulmonary Record(s), Face Sheet(s) Impatient Treatment, Outpatient Treatment, Emergency Treatment, Clinical Chart(s) Clinical Reports(s), Cardiopulmonary Record(s), Face Sheet(s), Impatient Treatment, Outpatient Treatment, Emergency Treatment, Clinical Chart(s) Clinical Report(s)/Document(s), Correspondence, Test Results, Questionnaire/Histories, Doctor's Handwritten Notes, documents received by other physicians, Autopsy Report(s), Histology Reports, Cytology Reports, CT Scans, MRI, Echocardiogram Videos Cardiac Catheterization Reports Cardiac Catheterization videos/CDs/films/reels Mammograms Myelograms. Pharmacy. Prescription records including NDC numbers and drug information handouts/manographs, Information regarding alcohol/substance abuse, consent forms, Medical Power of Attorney, Advance Directives, organ donation records, requests to amend records, log sheets, demographic information, nuclear medicine reports, ultrasound reports/videos/pictures, and Billing Records including all the statements itemized bills and insurance records.

This authorization is given in connection with pending claims and is valid and shall be honored by the health care provider for the entire time that claims remain pending in the referenced lawsuit. The party receiving information pursuant to this authorization is notified that the I understand that: authorization terminates when the lawsuit has concluded as to all parties.

The records used/disclosed pursuant to this authorization may include information relating lo Human Immunodeficiency Virus ("HIV"') or Acquired Immunodeficiency Syndrome (''AIDS"). treatment for or history of drug or alcohol abuse, or mental or behavioral health or psychiatric care.

Information disclosed by this authorization may be re-disclosed by the recipient of you Protected Health Information. Such re-disclosure will no longer be protected by this authorization.

I understand that I have a right to cancel this authorization at any time. If I wish to cancel this authorization, I understand that I must do so in writing and give it to the Medical Records Department of the medical facilities where I have been treated and/or evaluated to the party/class of persons requesting the above specified protected health information. I understand that cancellation will not apply to information that has already been released based on this authorization.

I have a right to receive a copy of this authorization. Copy of this authorization received

A copy or facsimile (fax) if this authorization IS as valid as the original.

My healthcare and the payment of my healthcare will not be affected if I refuse to sign this authorization.

This authorization is intended to comply with all release of information requirements mandated by HIPAA and/or federal law.

I have read the above/had it read to me and authorize the disclosure of the Protected Health Information.

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Signature Certificate
lock iconUnique Document ID: a0b88fd185aeef5133d5a21db0f5f362e0fd4a1f
Timestamp Audit
June 2, 2022 5:21 am -04HIPAA AUTHORIZATION Uploaded by Pete Perez Navejar - booking@pureconceptions.com IP