HIPAA AUTHORIZATION FORM

  • I hereby authorize use or disclosure of protected health information about me as described below.
    1. The following person or class of person may receive disclosure of protected health information about me: The North Law Firm, P.A. 14241 Metro Parkway, Suite 200 Fort Myers, Florida 33912
    2. The specific information that should be disclosed is: Written reports, office notes, nurses notes, medication sheets, admission forms, dictation reports, physicians orders, intake/outtake, clinical tests, operative information, cath lab, special tests/therapy, rhythm strips, nursing information, transfer forms, ER information, labor/delivery sum, OB nursing assess, postpartum flow sheet, itemized bills and UB-92.
    3. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
    4. I may revoke this authorization by notifying The North Law Firm, P.A. in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the medical provider or other entity to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
  • This authorization expires on the date below or upon occurrence of the following event that relates to me or for the purpose of the intended use or disclosure of information about me: Completion of pending legal action.
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