Medical Records Authorization (HIPAA)

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (LOUISIANA)

This Authorization complies with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. § 164.508, and applicable Louisiana law.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following provider(s), facility(ies), and their business associates to release my protected health information ("PHI"):

3. RECIPIENT(S) — WHO MAY RECEIVE THE RECORDS

4. RECORDS / INFORMATION TO BE RELEASED

☐ Complete treatment record (medical, hospital, laboratory, billing, and test results)
☐ Only records for the following date range: [__/__/____] to [__/__/____]
☐ Only records relating to the following incident/condition: [________________________________]

Record types (check all that apply):

☐ History and physical / office notes
☐ Physician and nursing notes
☐ Hospital / emergency-department records
☐ Diagnostic imaging (X-ray, MRI, CT) and reports
☐ Laboratory and pathology results
☐ Operative and procedure reports
☐ Physical therapy / rehabilitation records
☐ Prescription and medication records
☐ Itemized billing / invoice statements and insurance records
☐ Other: [________________________________]

5. PURPOSE OF DISCLOSURE

This disclosure is made at the request of the patient for the following purpose: evaluation, investigation, prosecution, and settlement of the patient's personal-injury claim, including legal representation.

☐ Other purpose: [________________________________]

6. HIPAA CORE-ELEMENT RECITALS

6.1 Expiration. This Authorization expires on the earlier of: (a) [__/__/____]; (b) the following event: [final resolution of the personal-injury claim]; or (c) if no date or event is stated, two (2) years from the date of signature.

6.2 Right to Revoke. I may revoke this Authorization at any time by written, signed notice to the provider, except to the extent action has already been taken in reliance on it.

6.3 No Conditioning. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

6.4 Redisclosure Notice. Information disclosed under this Authorization may be redisclosed by the recipient and may then no longer be protected by HIPAA or Louisiana law.

6.5 Copy. I am entitled to a copy of this signed Authorization.

7. SPECIAL-CATEGORY RECORDS

7.1 HIV/AIDS test results (La. R.S. 40:1171.4). Choose ONE:

☐ I authorize release of my HIV/AIDS test results as part of this Authorization.
☐ I refuse to release my HIV/AIDS test results. This Authorization expressly withholds HIV test results, which shall NOT be disclosed.

7.2 Other protected categories. Initial each category to be released; a blank line means that category is NOT authorized:

42 C.F.R. Part 2 notice (substance use disorder records): "42 CFR part 2 prohibits unauthorized use or disclosure of these records." Each disclosure made with the patient’s written consent must also be accompanied by a copy of the consent or a clear explanation of its scope. See 42 C.F.R. § 2.32.

8. COPY FEES AND RESPONSE TIME (LOUISIANA)

Under La. R.S. 40:1165.1, on a signed authorization a health care provider must furnish the entirety of the treatment records (medical, hospital, laboratory, billing, test results). Statutory copy charges: $1.00 per page for the first 25 pages, $0.50 per page for pages 26–350, and $0.25 per page thereafter, plus a handling charge not to exceed $25 (hospitals, nursing homes, and other providers) and actual postage. For records in digital format, copies provided in digital format are charged at the same per-page rate but the total digital charge may not exceed $100 plus actual postage. X-rays and imaging media carry a separate handling charge ($20 for hospitals; $10 for other providers) plus reproduction cost. Only one handling charge per request is allowed. Response time: under La. R.S. 40:1165.1(C), if a copy is not provided within a reasonable time not to exceed fifteen (15) days following receipt of the request and written authorization and the records must then be obtained by court order or subpoena, the provider may be liable for reasonable attorney fees and expenses (subject to a certified-mail notice and a 5-day cure). La. R.S. 13:3715.1 makes a signed authorization (or a lawful subpoena/court order) the exclusive method of disclosure.

9. SIGNATURE

Personal representative (if patient is a minor, incapacitated, or deceased):

10. NOTARY (OPTIONAL)

State of Louisiana, Parish of [________________]

Subscribed and sworn before me this [____] day of [____________], 20[____].

Notary Public: ________________________________ My commission expires: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA authorization core elements: https://www.ecfr.gov/current/title-45/section-164.508
• 42 C.F.R. Part 2 — Confidentiality of SUD patient records: https://www.ecfr.gov/current/title-42/part-2
• La. R.S. 40:1165.1 — Healthcare information; records; copy fees: https://codes.findlaw.com/la/revised-statutes/la-rev-stat-tit-40-sect-1165-1/
• La. R.S. 13:3715.1 — Medical/hospital records; subpoena and disclosure: https://www.legis.la.gov/legis/Law.aspx?d=77559
• La. R.S. 40:1171.4 — Confidentiality of HIV test result; disclosure (formerly 40:1300.14): https://law.justia.com/codes/louisiana/revised-statutes/title-40/rs-40-1171-4/
• La. R.S. 28:1 et seq. — Mental health / behavioral health: https://www.legis.la.gov/legis/Laws_Toc.aspx?folder=75&level=Parent