Missouri > Local Circuit Courts > 22nd Circuit (St. Louis City) > Civil
Authorization To Inspect And Copy Medical Records - Missouri
| Authorization To Inspect And Copy Medical Records Form. This is a Missouri form and can be used in Civil 22nd Circuit (St. Louis City) Local Circuit Courts . |
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AUTHORIZATION TO INSPECT AND COPY MEDICAL RECORDS TO: [insert name of health care provider] RE: [insert name of patient] This will authorize (the law firm of) ___________________________ ortheir representative to inspect and copy all office, medical and hospital records, 1 reports and other medical documents in your possession and relating to injuriesto the patients (insert body part(s) allegedly injured), and received by the patienton or about (insert date of alleged injury). This authorization also includesmedical records, reports and other medical documents in your possession whichrelate to any prior or subsequent complaints, injuries, illnesses or conditionsinvolving the same parts of the body and the same or similar conditions asdescribed below. This authorization includes but is not limited to records of allexaminations, treatments and tests, including in-patient, out-patient andemergency room, whether for diagnostic or prognostic purposes, consultation,reports, correspondence, x-rays, photographs, videotapes, MRIs, and CT Scans 2 [and post-mortem records] PROVIDED that the examinations, treatments and/ortests involve or relate to complaints, injuries, illnesses or conditions pertaining tothe following alleged injury: [insert allegation from Petition which describes injured part(s) of body]. The health care provider is neither required nor prohibited by law fromengaging in private conversations regarding the patients above-referenced care.The decision to enter into any such conversation is that of the health careprovider. However, any disclosure that exceeds the scope of this authorizationmay subject the health care provider to civil liability. This authorization remains in effect until the underlying claim is finallyresolved. Therefore, you may receive a supplemental request for documents.Provided you have an original authorization allowing you to provide records tothe party making the supplemental request, a written request for supplementaldocuments is sufficient, and no additional authorization is required. [The patient further requests that the health care provider supply completecopies of all documents produced pursuant to this authorization to patients 3attorneys, ___________, at their expense.] 1 As used in this authorization, the term report does not include any documentprepared in anticipation of litigation. 2 Insert if applicable. 3 If desired by Plaintiffs counsel.
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