COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . .F .3.201(2)F. . . . . . ........ : Index No. AUTHORIZATION FORM FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION : Calendar No. Instructions: All of the Bloc ks 1 - 6 must be comp leted. If any block is not completed then this “Authorization Form” will be co nsidered inc omp lete and defective and canno t be used. : JUDICIAL SUBPOENA PLEASE PRINT ALL INFORM ATION EXCEPT FO R REQU IRED SIGNATURE S. Plaintiff(s) -against- : Block 1: Identification of Patient PATIENT NAM E: ________________________________________________ DATE OF BIRT H: _____________________ : PATIENT ’S ADDRESS: ________________________________________________________________________________ Street [Apt. number, P.O. box - as applicable] , City, State & zip code. : SOCIAL SECURITY NUM BER or OTH ER IDENT IFIER:________________________________________________ Defendant(s) : Block .2: .Type. of. Records ./ .Information .to .be .Disclosed----CHEC K .O NLY. ON E OF TH E FO LLOW ING BO XES (A or B). If . . ... . ...... ......... . . ............... .... . neither box is checked or if both boxes are checked then this form will be considered defective and cannot be used. IF YOU W ANT BOT H TY PES O F RECO RDS D ISCLOSED YOU MU ST US E TW O SEP ARAT E FORM S - One for Each Purpose. 9 A. 9 B. Reco rds except for Psychotherapy Notes THE PEOPLE OF THE STATE OF NEW YORK P sychotherap y No tes only. DESCRIBE WHAT SPECIFIC RECORDS MAY BE DISCLOSED (examples: All records, X-Rays only, records for last 12 months) AN D/O R CHE CK ALL TH AT APPLY: 9 All Record s* 9 alcohol/drug evaluation o r treatment 9 HIV/Aids Status TO ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ *All includes inpatient/outpatient records, medical, dental, psychiatric, alcohol/chemical/substance abuse, HIV/Aids, pharmaceutical, hospital or physician records, office notes, narrative summaries, telephone messages, correspondence to/from/about me, diagnostic testing results, bills, GREETINGS: statements & invoices whether or not you created those records as long as the records are in your control or possession. Block 3: Persons, facility, or class YOU, that who are authorized to disclose (provide) theyou and / information: WE COMMAND of persons all business and excuses being laid aside, records each of you attend before _______________________________________________________________________________________________________ , the Honorable at the Court County of Block 4: Persons, facility,on the of persons who are authorized to, receive theo'clock in information: records / the in room , or class day of , 20 at noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ located at and his/her/its attorneys, agents, staff, rep resentatives, experts o r other designated p erson by them /it. Block 5: Expiration: This “A uthorization” will exp ire on _ ___ ___ ___ ___ ___ ___ (M M/DD /YY )[cannot exceed 1 year from d ate below] or on the following specific event:with this subpoena is punishable as a contempt of court and will make you liable Your failure to comply _____________________________________________________________________ to this subpoena was issued for a maximum penalty of $50 and all damages sustained as a • result ofreq uest for disclosure of medical reco rds/information is made at my req uest for the purpo se of legal proceedings. This your failure to comply. the Authorizing Signature Block 6: party on whose behalf • I understand that if the person or entity that receives the described records/information is not a health care provider or health plan covered by federal privacy regulations, the records/information may beone of the Justiceslonger protected Witness, Honorable , redisclosed and no of the by those regulations. Court in County, day of , 20 • I also understand that certain records may be protected by federal or state law and I am requesting that any and all such protected records be released under this authorization. • I also understand that I may revoke this authorization at any time by delivering/mailing a written revocation to the party (Attorney must sign above and type name below) or attorney or law firm named in Block 4 above. • If I revoke this authorization it will have no effect on actions already taken on reliance on this form. • The covered entity will not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs the authorization. Attorney(s) for • I authorize the disclosure of the records/information described. I have read and understand this form. I am the patient listed or am authorized to act on behalf of the patient as the patient’s personal representative. I also permit disclosure of the records upon presentation of a photocopy of this authorization. _________________________________________________________ Signature of Patient (or Patient’s Personal Representative, if applicable) Office and P.O. Address __________________________________ Date of Signature Telephone No.: Personal Representative’s Relationship / Capacity to Patient:____________________________________________________ Facsimile No.: Printed Name of Personal Representative: ____________________________________________________________________ E-Mail Address: Printed address & telephone number of Personal Representative: __________________________________________________ Mobile Tel. No.: Revised: October 2002 American LegalNet, Inc. www.USCourtForms.com