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Authorization To Release Information 145 - Iowa

Authorization To Release Information Form. This is a Iowa form and can be used in Miscellaneous Statewide .
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AUTHORIZATION TO RELEASE INFORMATION Name of Patient: ________________________________________ Date of birth: ________________ I. AUTHORIZATION FOR RELEASE OF INFORMATION AND FOR REDISCLOSURE I authorize ___________________________________________________________ whose address is___________________________________________________________________________ to disclose and deliver to __________________________________________________ whose address is ________________________________________________________________________________, the following information: _____________________________________________________________ _________________________________________________________________________. NOTE: If information includes mental health treatment, substance abuse treatment or HIV-related information it will not be released unless you agree to the release on the reverse side of this form. I understand the information is being disclosed and may be used only for legal and/or litigation purposes relating to claims and/or suit against _____________________________________________ _____________________________________ and/or arising out of incident(s) on or about ___________________. This authorization expires on ___________________ (not to exceed one year); or, if no date is specified, on the termination of the litigation or other proceedings for which this authorization was provided. I understand that I may refuse to sign this authorization or revoke this authorization at any time. I understand that my revocation or refusal to sign this authorization will not affect my ability to obtain health care services. I also understand that if I revoke, the revocation will take effect on the day it is received by the entity from whom disclosure is sought in writing. I understand that if the person or entity that receives the information requested is not covered by the federal privacy regulations or is not an individual or entity who has signed an agreement with such a person or entity, the information described above may be redisclosed and will no longer be protected by the regulations. Iowa and/or Federal law provides that I have a right to prohibit redisclosure of confidential medical information and further disclosure may not be had without my express written authorization, as indicated below. I further understand that the Recipient, WITHOUT FURTHER AUTHORIZATION, may redisclose said information to: A) Parties and their legal counsel, insurers, experts, potential experts, anyone against whom claim is or has been made, administrative agency and court officials hearing the claim, and any agents, employees, or representatives of any of said persons; OR INSTEAD B) ___ [CHECK ONLY IF APPLICABLE] ONLY to the following: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ I SPECIFICALLY AUTHORIZE AND CONSENT TO THE DISCLOSURE AND REDISCLOSURE DESCRIBED ABOVE. __________________________________________ Signature of Patient or patient's legal representative __________________________________________ Printed name and relationship of patient's legal representative © The Iowa State Bar Association 2016 IowaDocs® Form No. 145, Authorization to Release Information Revised January 2016 American LegalNet, Inc. www.FormsWorkFlow.com ___________________ Date II. AUTHORIZATION FOR CONSULTATION I understand that if the person or entity listed above is a physician, surgeon, physician's assistant, advanced registered nurse practitioner or mental health professional (provider) this authorization also permits ________________________________ [insert name of attorney requesting consultation] to consult with that provider about my medical history and condition relating to my claims described above, and further permits that health professional to render opinions regarding the cause of my condition and the prognosis for that condition. I understand that if the lawyer seeking consultation represents a party adverse to me, that lawyer shall provide a written notice to my lawyer and other counsel consistent with the Iowa Rules of Civil Procedure for service of a notice of deposition at least ten (10) days prior to such consultation. In order for the above consultation to be authorized, sign here and at the end of Section I. __________________________________________ Signature of Patient or patient's legal representative __________________________________________ Printed name and relationship of patient's legal representative III. SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED BY STATE OR FEDERAL LAW CONCERNING MENTAL HEALTH, SUBSTANCE ABUSE TREATMENT, AIDS-RELATED INFORMATION, OR GENETIC-RELATED INFORMATION I acknowledge that information to be released may include material that is protected by Federal and/or State law applicable to substance abuse, mental health, and/or AIDS-related information, and/or genetic-related information. I SPECIFICALLY AUTHORIZE the release of confidential information relating to:[Place "YES" or "NO" in ALL applicable boxes:] ____ Substance Abuse (Drug or Alcohol) Information from: ____________________________________________________________________________ ____________________________________________________________________________ ____ Mental Health Information from: NOTE: You have the right to inspect the disclosed mental health information at any time. ___________________ Date ____________________________________________________________________________ ____________________________________________________________________________ ____ AIDS-related Information, Diagnosis, and test results from: ____________________________________________________________________________ ____________________________________________________________________________ ____ Genetic testing, profiles, counseling, services, education, and medical histories which focus on genetically related diseases or conditions information, diagnosis, and test results from: ____________________________________________________________________________ ____________________________________________________________________________ __________________________________________ Signature of Patient or patient's legal representative __________________________________________ Printed name and relationship of patient's legal representative ___________________ Date © Th
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