BENEFICIARY SIGNATURE. Signature and date by beneficiary or authorized representative in acceptance of HIPAA clauses required to release information. If form not signed by beneficiary, attach notarized Power of Attorney (living individual), or Letters Testamentary and/ or Letters of Administration from the court (deceased individual). Exhibit C LIMITED AUTHORIZATION TO DISCLOSE HEALTH INFORMATION (Pursuant to the Health Insurance Portability and Accountability Act "HIPAA" of 4/14/03) TO: Patient Name: DOB: SSN: I, , hereby authorize you to release and furnish to: Litigation Management Inc., PO Box 241370, Cleveland, OH 44124 COPIES ONLY of the following information: * All medical records, including inpatient, outpatient, and emergency room treatment, all clinical charts, reports, documents, correspondence, test results, statements, questionnaires/histories, electronic medical data including information from Care Orchestrator and/or other databases, office and doctor's handwritten notes, and records received by other physicians. Said medical records may include all information regarding AIDS and HIV status. * All reports of autopsy, laboratory, histology, cytology, pathology, radiology, CT Scan, MRI, echocardiogram and cardiac catheterization reports. * All radiology films, mammograms, myelograms, CT scans, photographs, bone scans, pathology/cytology/histology/autopsy/immunohistochemistry specimens, cardiac catheterization videos/CDs/films/reels, and echocardiogram videos. * All pharmacy/prescription records including NDC numbers and drug information handouts/monographs. * All billing records including all statements, itemized bills, and insurance records.
