Harry Rein, J.D. M.D.
1877 Wingfield Drive Longwood FL 32779
Request and Authorization to Release and Provide Information
Patient:___________________________________________ Dated: ____________________
This is a request and authorizes all physicians, hospitals and medical attendants to furnish ALL of my medical reports, each and every page, legibly reproduced, laboratory data, letters about me, insurance forms and all other information requested by the undersigned to Harry Rein, J.D., M.D., or to any of his representatives or anyone associated with him.
This request and authority includes examination of originals of hospital records, X-rays, slides, and all other data, information and materials related to __________________________, including professional opinions, and all lab data, with NO exceptions, including HIV testing, any and all other protected information.
Please include a copy of each and every page of the medical record including but not limited to all notes written and dictated by physicians, consultants, nurses, and other health care providers. Do not omit any pages, items, reports, records, or dictated summaries even if they are unsigned and not yet proofread
All Other Authorization Is Cancelled, except those I (we) have previously executed which permit release of information to facilitate payment of outstanding bills by any first party health insurance carrier, my self-insured ERISA health insurance fund, Medicare or Medicaid. Please do not permit anyone else to inspect my records and please do not speak to anyone else about me unless legally required to do so.
Some state statutes provide:
"(1) Thar any health care practitioner licensed making a physical or mental examination of, or administering treatment to, any person shall, upon request of such person or his legal representatives, furnish copies of all reports made of such examination or treatment. The furnishing of such copies shall not be conditioned upon payment of a disputed fee for services rendered.
"(2) Such records (or information contained therein) may not be furnished to, and the medical condition of a patient may not be discussed with, any person other than the patient or the patient's legal representative or other health care provider involved in the care or treatment of the patient, except upon written authorization of the patient.
Statutes generally provide:
(1) Any licensed facility shall, upon request and only after discharge of the patient, furnish to any person admitted therein for care and treatment or treated thereat, or to any such person's guardian, curator, or personal representative or to anyone designated by such person in writing, a true and correct copy of all patient records, including X-rays, concerning such person, which records are in the possession of the licensed facility, except progress notes and consultation report sections of a psychiatric nature concerning the care and treatment performed by the licensed facility. The licensed facility shall further allow any such person to examine the original records in its possession, or microfilm or other suitable reproductions of the records, upon such responsible terms as shall be proposed to assure that the records will not be damaged, destroyed or altered.
Section 9 of the American Medical Association PRINCIPLES OF MEDICAL ETHICS states:
"A physician may not reveal the confidence entrusted to him in the course of medical attendance, or the deficiencies he may observe in the character of patients, UNLESS he is REQUIRED to do so by law or unless it becomes necessary to protect the welfare of the individual or of the community.
Witness Patient or patient's representative
(Spouse) if applicable