Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Authorization To Permit Interview Of Treating Physiciam By Defense Counsel (HIPAA) Form. This is a New York form and can be use in General Statewide.
Tags: Authorization To Permit Interview Of Treating Physiciam By Defense Counsel (HIPAA), UCS575, New York Statewide, General
AUTHORIZATION TO PERMIT INTERVIEW OF TREATING PHYSICIAN BY DEFENSE COUNSEL
TO:
Physician’s name and address
You are hereby authorized to discuss certain medical condition(s) involving:
with
Patient’s name
who is an attorney
Defense Attorney’s Name and Address
in a
representing
Defendant’s name
brought by
Type of Lawsuit
against
Plaintiff(s) Name
Defendant(s)
The lawsuit is currently pending and is at
Stage of Proceeding
YOU ARE PERMITTED TO DISCUSS ONLY THE FOLLOWING MEDICAL CONDITIONS WHICH ARE THE
SUBJECT MATTER OF THE AFOREMENTIONED LAWSUIT:
1. NOTHING CONTAINED HEREIN AUTHORIZES YOU TO DISCUSS ANYTHING ABOUT THIS PATIENT OTHER
THAN THE ABOVE-STATED MEDICAL CONDITIONS.
2. THE PURPOSE OF THIS INTERVIEW IS TO ASSIST THE DEFENDANT(S) IN THE DEFENSE OF THIS
LAWSUIT BROUGHT BY THIS PATIENT. THIS AUTHORIZATION IS NOT AT THE REQUEST OF YOUR
PATIENT.
3. YOUR WILLINGNESS TO PARTICIPATE IN THIS INTERVIEW IS ENTIRELY VOLUNTARY. YOU ARE FREE
TO DECLINE THE REQUEST FOR SAID INTERVIEW.
4. You are permitted to disclose information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except
psychotherapy notes, and CONFIDENTIAL HIV RELATED INFORMATION only if specifically initialed below:
Alcohol/Drug Treatment;
Mental Health Information;
HIV-Related Information
(Indicate by Initialing):
5. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient
is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization.
If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State
Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These
agencies are responsible for protecting my rights.
6. I have the right to revoke this authorization at any time by writing to the health care provider listed. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
7. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
benefits will not be conditioned upon my authorization of this disclosure.
8. Information disclosed under this authorization might be redisclosed by the recipient (except as noted in Item 5 above), and this
redisclosure may no longer be protected by federal or state law.
9. If not the patient, name of person signing form:
10. Authority to sign on behalf of patient:
11.Date this authorization will expire:
Signature
Date
UCS-575 (2/08)
American LegalNet, Inc.
www.FormsWorkflow.com
