Stanley & Associates, PLLC
HIPAA Authorization to Disclose Protected Health Information

    Note: an asterisk (*) denotes a required field.

    I hereby authorize the release of information to Stanley and Associates, PLLC, for the medical records pertaining to me.  This release applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA").

    The information will be used or given out for the purposes of handling the law firm's duties in the investigation and possible litigation of claims in which I am involved.  This authorization is initiated at my request and the health information will be disclosed at my request. Information used or disclosed pursuant to this authorization may be subject to re-disclosure or shared by the persons or organizations receiving the information and is no longer protected.

    STANLEY AND ASSOCIATES are permitted to receive the information and is hereby appointed as my attorneys-in-fact/representatives for the limited purpose of obtaining and using any and all information the releasing persons or organization may have concerning treatment or services rendered to the undersigned for any reason, whether inpatient or outpatient, including but not limited to digital or physical copies of the following:

    • Face sheet;
    • Intake, history, and physical;
    • Emergency room notes (handwritten and/or typed);
    • EKG, Holter monitor, Echo, and PFT;
    • Lab/pathology results and reports;
    • Results of summary testing;
    • Operative report;
    • Radiology records, X-rays, MRIs, and related notes and reports;
    • Consultation notes and reports;
    • Charts, progress notes, case notes, nurse's notes, and dictation;
    • Opinions, diagnoses, prognoses, and treatment plans;
    • Orders;
    • Statements and/or bills;
    • Dental records, notes, reports, summaries, and treatment plans;
    • Medication summary, pharmaceutical records including but not limited to date of prescription, prescribing physician, name of drug, dosage and amount dispensed; AND
    • Any other medical information regarding any treatment, including documents to and from other health care providers, attorneys, insurance companies, etc.

    I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.  I understand that the specified information to be released may include:  history, diagnosis, and/or treatment of drug or alcohol abuse, mental illness, or communicable and non-communicable diseases, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS).

    I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for participation in research programs, or authorization of the release of testing for pre-employment purposes.  I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon this authorization.  I understand that I may be charged a retrieval/processing fee and for copies of my medical records according to Texas Hospital Licensing Law.

    Unless revoked sooner, this authorization expires one (1) year from the date of my signature below.

    A photocopy or facsimile transmission of this authorization has the same force and effect as an original.

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