AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

(Check all necessary boxes to accept terms)


The following individual or organization is authorized to make the disclosure:
I hereby authorize the above-stated organization or individual to release to Andrew Yuspeh, Jason Rappaport, and any employee of Yuspeh Rappaport Law LLC, 5001 Mayfield Road, Suite 210, Lyndhurst, Ohio 44124, copies of all information comprising the entire record for the individual named below, including, but not limited to:

 Final Diagnoses
Discharge Summaries
Histories
Physical Examinations
Consultation Reports
Diagnostic Test Reports
Diagnostic Images
Billing/Account Records
Insurance Records
Operative Reports
Pathology Reports
Progress Notes
Physician's Orders
Office Notes
All computer entries/notes/electronic mail
Patient forms and questionnaires
Emergency Room Treatments
Therapy Notes
Clinical Notes Medication Records
Evaluations
HIV/AIDS Results
Correspondence regarding patient Pathology Specimens including
Phone/Verbal Communication


I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immune deficiency syndrome (AIDS), information concerning testing or treatment of AIDS and AIDS-related conditions, drug or alcohol abuse, human immunodeficiency virus (HIV), drug-related conditions, alcoholism and/or psychiatric/psychological conditions, including specifically, but not limited to, those records contemplated by 42 U.S.C. § 290 dd-2, 42 U.S.C. § 290 dd-3 and 42 U.S.C. § 290 ee-3. This information may be disclosed to the above—named individual or organization for the purpose of the processing of a claim for bodily injury, emotional harm, or other claim for damages. Review of the records is also hereby authorized.


To assist in the identification and location of these records, I am providing the following information:


I hereby authorize the use of a photocopy of this release as an original.


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 that revocation will not apply to information that has already been released in response to this authorization. I understand that revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this
authorization will expire in six (6) months.


I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I understand that the organization or individual identified above cannot condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I understand I may inspect or copy the information to be used or disclosed, as provided in C.F.R. 164.524. I understand that 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 disclosure of my health information, I can contact the Privacy Officer or other individual at the organization identified above.




**This release is intended to comply with the Health Information Portability and Accountability Act (HIPAA), the individual forms of health care providers or health care institutions. Acceptance of this form is required to avoid the expense and inconvenience of complying with an institution’s separate form, or requiring you to respond to a subpoena for the information.

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