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  1. <div data-section-type="1" data-id="H1BnPYCZJX" data-time="1527011684496" style="text-align: center;" class="ps-section"><b style="background-color: initial;"><span style="color: rgb(67, 67, 67); font-size: 10px;">HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF&nbsp;</span></b><b style="background-color: initial; color: rgb(67, 67, 67); font-size: 10px;"><b style="background-color: initial;">PATIENT INFORMATION PURSUANT TO 45 CFR 164.508</b></b></div>
  2. <div data-id="S14hPYCby7" data-time="1527011684496" data-section-type="1" class="ps-section"><span style="background-color: initial; color: rgb(67, 67, 67); font-size: 10px;">To:&nbsp;</span></div>
  3. <div data-id="ByQhvtC-1X" data-time="1527011684496" data-section-type="1" class="ps-section"><span style="background-color: initial; color: rgb(67, 67, 67); font-size: 10px;">Re:&nbsp;&nbsp;{{{01InjuredFullName}}}&nbsp;&nbsp;{{{09InjuredDOB}}}&nbsp;&nbsp;{{{08InjuredSocial}}}</span></div>
  4. <div data-id="rJGhPtAWJQ" data-time="1527011684495" data-section-type="1" class="ps-section"><span style="color: rgb(67, 67, 67); background-color: initial; font-size: 10px;">I authorize and request disclosure of my protected health information described below and authorize release to:<br></span><b style="font-size: 10px; background-color: initial; color: rgb(67, 67, 67);">Dan Newlin & Partners, P.A.<br></b><b style="font-size: 10px; background-color: initial; color: rgb(67, 67, 67);">7335 W. Sand Lake Road, Suite 300<br></b><b style="font-size: 10px; background-color: initial; color: rgb(67, 67, 67);">Orlando, FL 32819<br></b><span style="color: rgb(67, 67, 67); font-size: 10px; background-color: initial;">I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), alcohol and drug abuse, and mental health. This protected health information is being disclosed for the purposes of a legal claim or proceeding. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information for the following dates of service to include the following:<br></span><span style="color: rgb(67, 67, 67); font-size: 10px; background-color: initial;">Date(s) of Service   __________________________   to ____________________________</span></div>
  5. <table data-id="S1-2wtCWJ7" data-time="1527011684495" data-section-type="6" style="border-color: transparent;" class="ps-section"><tbody data-id="BklWtgsbJX" data-time="1526997113126" class="ps-section"><tr data-id="B1ZZYxiWJQ" data-time="1526997113126" class="ps-section"><td data-id="ryM-Fgs-JQ" data-time="1526997113126" width="2.74%" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="rkQbFljby7" data-time="1526997113126" class="ps-section"><span style="font-size: 10px; color: rgb(0, 0, 0);">☐</span><span style="color: rgb(0, 0, 0);"><br></span></div>
  6. </td><td data-id="rJVZKxjbyX" data-time="1526997113126" width="45.26%" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="r1Hbtxs-JQ" data-time="1526997113126" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">Entire Chart: to include each and every page, including but not limited to: office notes, intake sheets, history and physical, consultation notes, inpatient, outpatient and emergency room records, discharge summaries, laboratory reports and results.</span><br></div>
  7. </td><td data-id="ByOFxiZy7" data-time="1526997120507" width="2.53%" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="BJx_FesbJQ" data-time="1526997120507" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">☐</span><br>&nbsp;</div>
  8. </td><td data-id="By6FgiZyX" data-time="1526997124688" width="49.47%" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="HkeaKxibkX" data-time="1526997124688" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">All ERISA, group health, medical, worker's compensation etc., insurance or collateral source benefits, provider records, to include insurance & submission claims forms, payout records, benefits, policy information, subrogation language and lien claims.</span><br></div>
  9. </td></tr><tr data-id="H1IbKeiW1Q" data-time="1526997113126" class="ps-section"><td data-id="BJvbKls-y7" data-time="1526997113126" width="2.84%" height="63" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="SkuZtliZkm" data-time="1526997113126" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">☐</span><br>&nbsp;</div>
  10. </td><td data-id="HJYWKxj-yQ" data-time="1526997113126" width="45.16%" height="63" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="HyqWKeoZ1Q" data-time="1526997113126" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">All physicals, occupational/rehab records, consultations and progress notes.</span><br></div>
  11. </td><td data-id="HJ-uKlib17" data-time="1526997120507" width="2.53%" height="63" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="S1fuYgi-17" data-time="1526997120507" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">☐</span><br>&nbsp;</div>
  12. </td><td data-id="HkWaKls-k7" data-time="1526997124688" height="63" width="49.37%" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="SkzpFxsZkQ" data-time="1526997124688" class="ps-section">&nbsp;<span style="color: rgb(0, 0, 0); font-size: 10px;">All employment, personnel or wages records.</span><br></div>
  13. </td></tr><tr data-id="H1IbKeiW1Q" data-time="1526997113126" class="ps-section"><td data-id="BJvbKls-y7" data-time="1526997113126" width="2.84%" height="42" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="SygkH-i-yX" data-time="1526997302684" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">☐</span></div>
  14. </td><td data-id="HJYWKxj-yQ" data-time="1526997113126" width="45.16%" height="42" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="rkxblWjWyX" data-time="1526997225481" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment of denial of benefits.</span></div>
  15. </td><td data-id="HJ-uKlib17" data-time="1526997120507" width="2.53%" height="42" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="BJevSWsbkX" data-time="1526997310708" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">☐</span></div>
  16. </td><td data-id="HkWaKls-k7" data-time="1526997124688" height="42" width="49.37%" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="SJesebsZJX" data-time="1526997235445" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">Final narrative report to include impairment rating, future medical expenses and any other pertinent information related to your treatment of our client.</span></div>
  17. </td></tr><tr data-id="H1IbKeiW1Q" data-time="1526997113126" class="ps-section"><td data-id="BJvbKls-y7" data-time="1526997113126" width="2.84%" height="42" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="BkxkLZj-yQ" data-time="1526997318991" class="ps-section"><span style="font-size: 10px; color: rgb(0, 0, 0);">☐</span></div>
  18. </td><td data-id="HJYWKxj-yQ" data-time="1526997113126" width="45.16%" height="42" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="B1e8bbi-1Q" data-time="1526997246136" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">All X-ray and imaging reports.</span></div>
  19. </td><td data-id="HJ-uKlib17" data-time="1526997120507" width="2.53%" height="42" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="SygvLbj-k7" data-time="1526997326797" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">☐</span></div>
  20. </td><td data-id="HkWaKls-k7" data-time="1526997124688" height="42" width="49.37%" style="border-color: transparent;" class="ps-section ps-parent"><div data-section-type="1" data-id="S1xWfZj-J7" data-time="1526997256530" class="ps-section"><span style="color: rgb(0, 0, 0); font-size: 10px;">Other: ___________________________________</span></div>
  21. </td></tr></tbody></table><div data-id="ryx3PYAbJm" data-time="1527011684495" data-section-type="1" class="ps-section"><span style="font-size: 10px; background-color: initial;">This authorization is given in compliance with federal consent requirements for release of alcohol or substances abuse records of 42 CF 2.13, the restrictions of which have been specifically considered and expressly waived. I understand the following: [CFR Sec. 164.508(c)(2)(i-iii)] a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization, b. the information released in response to this authorization may be re-disclosed to other parties, c. my treatment or payment for my treatment cannot be conditioned on the signing of this authorization. Any fascimile, copy or photocopy shall have the same effect as an original and authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires. The undersigned patient, hereby executes this authorization in compliance with the Federal Health Insurance Portability and Accountability Act, HIPAA, 45 CFR 164.104.</span><br></div>
  22. <table data-id="ByhDFA-J7" data-time="1527011684495" data-section-type="6" style="border-color: transparent;" class="ps-section"><tbody data-id="BygXHh9l1X" data-time="1526930490575" class="ps-section"><tr data-id="Sy-XS29gkm" data-time="1526930490575" class="ps-section"><td data-id="HyzQS29e17" data-time="1526930490575" style="border-color: transparent;" width="49.89%" class="ps-section ps-parent"><div data-section-type="1" data-id="HJ7QS35x1X" data-time="1526930490575" class="ps-section"><span style="font-size: 10px;">&nbsp;<field data-element-type="field" data-id="5b031c5109e0ee0f92821b21" data-uuid="161124ca-7692-4a1f-b877-17076de79ed2" data-name="signature" data-type="signature" data-label="Signature" contenteditable="false" data-required="true"></field></span></div>
  23. </td><td data-id="BJVXr25xkQ" data-time="1526930490575" style="border-color: transparent;" width="50.11%" class="ps-section ps-parent"><field data-element-type="field" data-id="5b041ee17349d64be9c0f97f" data-uuid="2fc35caa-9561-45c3-93a9-38952f688257" data-name="date" data-type="date" data-label="Date" contenteditable="false" data-required="true"></field><span style="font-size: 10px;">&nbsp;</span></td></tr><tr data-id="SJI7Hn5xJQ" data-time="1526930490575" class="ps-section"><td data-id="H1wQr25ly7" data-time="1526930490575" style="border-color: transparent;" height="42" width="49.89%" class="ps-section ps-parent"><div data-section-type="1" data-id="rkuXH39xkm" data-time="1526930490575" class="ps-section"><b style="font-size: 10px;">Signature of Patient or Legally Authorized Representative&nbsp;</b></div>
  24. </td><td data-id="Byt7Bn5eym" data-time="1526930490575" style="border-color: transparent;" height="42" width="50.00%" class="ps-section ps-parent"><div data-section-type="1" data-id="Bk97rnqg17" data-time="1526930490575" class="ps-section"><b style="font-size: 10px;">Date</b></div>
  25. </td></tr><tr data-id="SJI7Hn5xJQ" data-time="1526930490575" class="ps-section"><td data-id="H1wQr25ly7" data-time="1526930490575" style="border-color: transparent;" height="42" width="49.89%" class="ps-section ps-parent"><b style="font-size: 10px;">Name and Relationship of Legally Authorized Representative to Patient</b></td><td data-id="Byt7Bn5eym" data-time="1526930490575" style="border-color: transparent;" height="42" width="50.00%" class="ps-section ps-parent"><b data-id="HkbYcA9bk7" data-time="1526996624901" style="font-size: 10px;"><br data-id="BJAtR9-J7" data-time="1526996613639"></b></td></tr><tr data-id="SJI7Hn5xJQ" data-time="1526930490575" class="ps-section"><td data-id="H1wQr25ly7" data-time="1526930490575" style="border-color: transparent;" height="42" width="49.89%" class="ps-section ps-parent"><b data-id="rkztqR9bkm" data-time="1526996624901" style="font-size: 10px;">Witness Signature</b></td><td data-id="Byt7Bn5eym" data-time="1526930490575" style="border-color: transparent;" width="50.00%" height="42" class="ps-section ps-parent"><b data-id="rJQKqAcbJX" data-time="1526996624901" style="font-size: 10px;">Date</b></td></tr></tbody></table>
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