Medical Records Authorization (HIPAA) - Montana

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA) — MONTANA

This Authorization is executed in connection with a personal-injury matter so that the Patient and/or the Patient's attorney may obtain the Patient's medical records.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following health-care provider(s), facility(ies), clinic(s), pharmacy(ies), laboratory(ies), insurer(s), or custodian(s) of records to release the Protected Health Information ("PHI") described below:

3. RECIPIENT(S) — PERSON(S) AUTHORIZED TO RECEIVE RECORDS

4. RECORDS AUTHORIZED FOR RELEASE

Date range of records: [__/__/____] to [__/__/____] (or ☐ all dates).

Check each category of records to be released:

• ☐ Complete medical record / designated record set
• ☐ History and physical examination reports
• ☐ Office/progress/treatment notes
• ☐ Hospital and emergency department records
• ☐ Operative and surgical reports
• ☐ Physician orders
• ☐ Laboratory and pathology reports
• ☐ Radiology/imaging reports and films (X-ray, MRI, CT, mammogram, ultrasound)
• ☐ Physical therapy / rehabilitation records
• ☐ Prescription and pharmacy/medication records
• ☐ Billing statements, itemized charges, and payment records
• ☐ Diagnostic test results
• ☐ Discharge summaries
• ☐ Other (specify): [________________________________]

5. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

The following categories are protected by heightened confidentiality rules. Initials document the Patient’s request but do not replace a standalone authorization or consent when governing law requires one. In particular, psychotherapy notes and Part 2 records must not be released solely on these initials; attach a compliant standalone document.

Part 2 warning: Initialing this general authorization does not itself create a consent that satisfies 42 C.F.R. § 2.31. Use a standalone consent containing every applicable current § 2.31 element. If the records will be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding, § 2.31(d) prohibits combining that consent with a consent for any other purpose. Each disclosure made under a valid consent must also carry one of the notices permitted by § 2.32(a) and a copy of the consent or a clear explanation of its scope under § 2.32(b).

6. PURPOSE OF DISCLOSURE

The purpose of this disclosure is:

• ☐ Legal representation / evaluation, prosecution, or settlement of the Patient's personal-injury claim
• ☐ At the request of the Patient
• ☐ Other (specify): [________________________________]

7. HIPAA REQUIRED STATEMENTS

7.1 Expiration. This Authorization expires on [__/__/____], or upon the following event: [________________________________]. If no date or event is specified, this Authorization expires upon final resolution of the Patient's personal-injury claim or three (3) years from the date of signature, whichever occurs first.

7.2 Right to Revoke. I understand that I may revoke this Authorization at any time by delivering written notice to the provider/custodian identified in Section 2. Revocation will not apply to information already released in reliance on this Authorization before the provider receives my written revocation. (45 C.F.R. § 164.508(c)(2)(i).)

7.3 No Conditioning of Treatment. I understand that the provider may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

7.4 Redisclosure Notice. I understand that information disclosed under this Authorization may be redisclosed by the Recipient and may then no longer be protected by HIPAA. (Special-category records under Section 5 remain subject to the redisclosure prohibitions of 42 C.F.R. Part 2 and applicable Montana law.)

7.5 Right to a Copy. I understand that I am entitled to a copy of this signed Authorization.

7.6 Voluntary. I understand that signing this Authorization is voluntary.

8. MONTANA COPY-FEE AND RESPONSE-TIME NOTE

Under Mont. Code Ann. § 50-16-541, upon receipt of a written request from a patient to examine or copy recorded health care information, a health care provider must — as promptly as required but no later than 10 days after receiving the request — make the information available for examination without charge during regular business hours, or provide a copy if requested; inform the patient if the information does not exist or is maintained by another provider; or, where the information is in use or unusual circumstances have delayed handling, state in writing the reason and the earliest date (not later than 21 days after the request) the information will be available.

Fees (Mont. Code Ann. § 50-16-540): a reasonable fee may not exceed $0.50 per page for a paper copy or photocopy, and may include an administrative fee not exceeding $15 for searching and handling the health care information. The provider is not required to create or reformulate a record to satisfy a particular format request and may withhold copies until the fee is paid.

Under the HIPAA right of access (45 C.F.R. § 164.524), a covered entity must generally act on a patient's request within 30 days (with one 30-day extension on notice).

9. SIGNATURE

Personal Representative (if Patient is a minor, incapacitated, or deceased)

Notary (optional)

State of Montana, County of [________________________].

Subscribed and sworn to before me on [__/__/____] by [________________________________].

Sources and References

• HIPAA authorization core elements — 45 C.F.R. § 164.508: https://www.law.cornell.edu/cfr/text/45/164.508
• HIPAA right of access — 45 C.F.R. § 164.524: https://www.law.cornell.edu/cfr/text/45/164.524
• Substance use disorder records — 42 C.F.R. Part 2: https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2
• Mont. Code Ann. § 50-16-541 (patient examination and copying): https://mca.legmt.gov/bills/mca/title_0500/chapter_0160/part_0050/section_0410/0500-0160-0050-0410.html
• Mont. Code Ann. § 50-16-540 (reasonable fees allowed): https://mca.legmt.gov/bills/mca/title_0500/chapter_0160/part_0050/section_0400/0500-0160-0050-0400.html
• Mont. Code Ann. § 50-16-1009 (confidentiality of HIV records): https://law.justia.com/codes/montana/title-50/chapter-16/part-10/section-50-16-1009/
• Mont. Code Ann. § 53-21-166 (confidentiality of mental health records): https://law.justia.com/codes/montana/title-53/chapter-21/part-1/section-53-21-166/