My attorneys are hereby authorized to act on my behalf regarding all insurance and legal matters. The patient identifiable health information received pursuant to this release authorization is to be used for the following purpose:
No-fault (PIP, Med Pay) insurance claims, liability claims, underinsured motorist claims, workers’ compensation claims, and all other insurance or legal matters related to my injuries or health condition.
ABILITY TO RECEIVE TREATMENT: I understand that my ability to receive treatment from this provider does not depend on my signing this form. Pursuant to 45 CFR 164.508(c)(2).
RIGHT TO REFUSE: I understand that I have a right to refuse to sign this release authorization and do so under my own free will.
RIGHT OF REVOCATION: I have the right to revoke this release authorization at any time. The revocation must be in writing and delivered to Max Sparwasser Law Firm, LLC. The revocation will not apply to records and information that has already been provided.
EXPIRATION: Unless earlier revoked, this authorization will expire upon the termination of the representation by Max Sparwasser Law Firm, LLC.
PATIENT RIGHTS: I have the right to inspect and/or copy the information to be disclosed, to inspect and amend my medical records, and to an accounting of the use and disclosure of my health information to any third party, as provided in CFR 164.528.
RE-DISCLOSURE: I understand that there is a potential for unauthorized re-disclosure of the information and that the re-disclosed information may not be protected by federal confidentiality rules.
SENSITIVE INFORMATION: I acknowledge and hereby consent to such, that the release information may contain alcohol, drug abuse, genetic information, psychiatric, HIV testing, HIV results or AIDS information.
