HIPAA (Health Insurance Portability and Accountability Act) Form Generator
Completing this form allows us to obtain medical records from your various providers. Sometimes the court requires us to send your medical authorization to the defense counsel or insurance carrier to obtain relevant medical records.To complete this form, follow these instructions: • Fill in your name, date of birth, and address, as well as your full Social Security Number (your Social Security Number is not saved on this website). • Enter the name and address of your medical provider for which medical records are being requested. You will need a separate HIPAA form for each provider. • The form defaults to sending the records to our law firm. • Choose which the medical records are to be released. If you select a specific date range, the form will expand to allow you to enter the date range. Please check “all” if all records are to be released. If requesting one specific report, please check “other” and specify the date of the report. • Check the reason for release of information. • Select which case type the records are being used for, including Workers’ Compensation, Social Security Disability, or Personal Injury. • Lastly, check the box that authorizes the law firm to speak to your health care provider(s) about your case. • Click “Generate HIPAA.” The form will be generated as a PDF to your computer, along with a letter of transmittal to whoever is receiving your records. • Print the documents. • Initial on the lines in Box 9a if Alcohol/Drug, Mental Health, or HIV-Related information is to be released. • Initial box 9b to allow contact with your physician if necessary. • Sign and date on the bottom line in BLUE INK.
Patient Information
Medical Record Release Information
Check the box to authorize (Name of Individual Health Care Provider) to discuss your health information with Meggesto, Crossett & Valerino, LLP MCV Law.
