FOR THE LEGAL EFFECT OF THE USE OF THIS FORM, CONSULT YOUR LAWYER THE IOWA STATE BAR ASSOCIATION Official Form No. 145 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 , the following information: whose address is 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 the day of , . 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, except 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 Date Printed name and relationship of patient's legal representative: © The Iowa State Bar Association 2004 IOWADOCS ® 145 AUTHORIZATION TO RELEASE INFORMATION Revised July 2004 American LegalNet, Inc. www.USCourtForms.com Il. 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. l 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 Date 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 OR AIDS-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 AlDS-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: (Name of agencies, facilities, or individuals) Mental Health Information from: NOTE: You have the right to inspect the disclosed mental health information at any time. (Name of agencies, facilities, or individuals) AlDS-related Information, Diagnosis, and test results from: (Name of agencies, facilities, or individuals) Signature of Patient or patient's legal representative Date Printed name and relationship of patient's legal representative: Furthermore, I SPECIFICALLY AUTHORIZE disclosure and redisclosure of this confidential information to all of the persons referred to in the Redisclosure Section I. In order for the above information to be released, you must sign here AND at the end of Section I. If mental health information is being disclosed, I acknowledge receipt of a copy of this Authorization. Signature of Patient or patient's legal representative Date Printed name and relationship of patient's legal representative: Federal and/or State law specifically require that any disclosure or redisclosure of substance abuse, alcohol or drug, mental health, or AlDS-related information must be accompanied by the following written statement: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. See also Chapter 228 and Chapter 141(A) of the Iowa Code and other applicable laws. NOTE: PHOTOCOPY OF THIS SIGNED AUTHORIZATION SHALL BE AS EFFECTIVE AS THE ORIGINAL. American LegalNet, Inc. www.USCourtForms.com