HIPAA medical records request

Phone: 

June 3, 2026


Attn: Medical Records / Health Information Management


Re: AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Pursuant to 45 CFR §164.508

PATIENT INFORMATION
  Full name:        
  Date of birth:    
  SSN (last 4):     XXX-XX- (for record matching only)

To Whom It May Concern:

I, , hereby authorize the use and disclosure of my protected health information ("PHI") as described below. This authorization is given freely and is intended to comply with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and 45 CFR §164.508.

1. SPECIFIC DESCRIPTION OF INFORMATION TO BE USED OR DISCLOSED
   All medical records related to the motor-vehicle accident that occurred on , including but not limited to: emergency department records, history and physical exam notes, progress notes, consultation reports, operative reports, discharge summaries, physician orders, nursing notes, laboratory and pathology results, diagnostic imaging reports and images (X-ray, MRI, CT), medication and prescription records, physical therapy notes, billing statements, and itemized charges, for the treatment period of  through present.

2. PERSON(S) AUTHORIZED TO MAKE THE USE OR DISCLOSURE (the holder of the records)
   
   
   and any of its physicians, nurses, therapists, billing personnel, custodians of records, and affiliated entities holding the information described above.

3. PERSON(S) TO WHOM THE USE OR DISCLOSURE MAY BE MADE
   
   

4. PURPOSE OF THE USE OR DISCLOSURE
   To allow the patient to obtain a complete copy of the records described above for personal use in connection with the evaluation, documentation, and pursuit of a motor-vehicle accident claim, including but not limited to communicating with insurers, evaluating settlement options, and (if necessary) retaining legal counsel. "At the request of the individual" is a valid stated purpose under 45 CFR §164.508(c)(1)(iv).

5. EXPIRATION
   This authorization expires on June 3, 2027, or upon the earlier written revocation by the patient.

6. RIGHT TO REVOKE
   I understand that I have the right to revoke this authorization at any time by submitting a written revocation to the provider listed in section 2, except to the extent that the provider has already acted in reliance on this authorization. Revocation will not affect any actions taken before the provider received notice of the revocation.

7. POTENTIAL FOR REDISCLOSURE
   I understand that once my protected health information is disclosed under this authorization, the recipient may redisclose it and the information may no longer be protected by the federal Privacy Rule (45 CFR Part 164, Subpart E).

8. NO CONDITIONING OF TREATMENT OR PAYMENT
   I understand that the provider may not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this authorization, except in the limited circumstances permitted by 45 CFR §164.508(b)(4).

9. SPECIAL CATEGORIES OF INFORMATION
   This authorization specifically includes (where applicable to the records held by the provider): records relating to HIV/AIDS, mental health, alcohol or substance use, and genetic information. If the provider holds such records and additional consent is required by state or federal law (e.g., 42 CFR Part 2 for substance-use records), the patient consents to their release under this authorization. If the provider requires a separate form for any of these categories, please contact the patient at the phone or email above.

10. DELIVERY OF RECORDS
    Please deliver the records to the recipient named in section 3. The patient prefers electronic delivery (encrypted email or secure portal) when available; otherwise, paper copy by U.S. mail to the recipient's address is acceptable. Per 45 CFR §164.524(c)(4), fees for copies shall not exceed reasonable cost-based fees.

Sincerely,


Patient signature: _____________________________________________
                   

Date signed:       _____________________________________________

If signed by a personal representative (e.g., parent, legal guardian, healthcare power of attorney), describe authority:
_______________________________________________________________________

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