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 DiagnosesDischarge SummariesHistoriesPhysical ExaminationsConsultation ReportsDiagnostic Test ReportsDiagnostic ImagesBilling/Account RecordsInsurance RecordsOperative ReportsPathology ReportsProgress NotesPhysician's OrdersOfﬁce NotesAll computer entries/notes/electronic mail Patient forms and questionnairesEmergency Room TreatmentsTherapy NotesClinical Notes Medication RecordsEvaluationsHIV/AIDS ResultsCorrespondence regarding patient Pathology Specimens includingPhone/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:Name: Social Security Number: Date of Birth: 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.Type Your Name Your Email (required) Today's Date: Client Signature (use finger, mouse, or stylus (required) **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.