Medical Records Authorization (HIPAA) - West Virginia

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA) — WEST VIRGINIA

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 West Virginia 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. WEST VIRGINIA COPY-FEE AND RESPONSE-TIME NOTE

Under W. Va. Code § 16-29-1, upon a written request from the patient, the patient's HIPAA personal representative, or an authorized agent or representative, a health-care provider must furnish a copy of all or the requested portion of the record within no more than thirty (30) days of receipt; if the provider routinely stores records electronically and the requester so requests, the copy must be provided in an electronic format.

Fees under W. Va. Code § 16-29-2:

• Patient or personal representative: no more than a fee consistent with HIPAA, plus applicable taxes.
• A person other than the patient/PR (on a HIPAA-compliant written authorization): no more than a $20 search-and-handling fee, $0.40 per page for paper copies (adjusted annually for the CPI for medical care services), plus postage if mailing is requested, plus applicable taxes.
• Electronic copies (where stored electronically): no more than $0.20 per page, but in no event more than $150 inclusive of all fees (including search and handling), except applicable taxes.
• Certification by affidavit: $10.
• No charge may be imposed on an indigent person (or authorized representative) where the records support a claim or appeal under the Social Security Act, limited to one set of copies per provider.

Under the HIPAA right of access (45 C.F.R. § 164.524), a covered entity must generally act on a 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 West Virginia, 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
• W. Va. Code § 16-29-1 (copies of health care records): https://code.wvlegislature.gov/16-29-1/
• W. Va. Code § 16-29-2 (reasonable expenses; fees): https://code.wvlegislature.gov/16-29-2/
• W. Va. Code § 27-3-1 (confidentiality of mental health information): https://code.wvlegislature.gov/27-3-1/
• W. Va. Code § 16-3C-3 (HIV/AIDS testing confidentiality): https://code.wvlegislature.gov/16-3C-3/