[Note: Form adopted as Appendix XII-C July 27, 2006 to be effective September 1, 2006.]
Appendix XII-C (new)
AUTHORIZATION TO RELEASE PRIVATE HEALTH CARE INFORMATION
AND FOR VOLUNTARY INTERVIEW
TO: __________________________ RE: _______________________
__________________________ DOB: _______________________
__________________________ SS#: _______________________
I hereby authorize you to disclose my protected health information to and to
participate in a voluntary interview with:
_________________________________________
_________________________________________
_________________________________________
In defending against the lawsuit I have filed against ___________________, the
defendant is entitled to seek to interview witnesses with relevant information. Your
participation in any such interview is entirely voluntary. You have the right to have my
attorney present at the interview.
You may disclose protected information reasonably related to the medical
condition I have place in issue by my lawsuit. That condition relates to:
_________________________________________
_________________________________________
This authorization may be revoked by me at any time, and expires 120 days from
the date I execute the authorization as indicated below. If you have questions relating to
the scope of this authorization, you may contact your own attorney or my attorney:
__________________________________________
__________________________________________
__________________________________________
Patient signature: ___________________________________ Date: _____________
