AUTHORIZATIONFORTHE RELEASEOFMENTALHEALTHRECORDS PURSUANTTO45CFR164.508(A)(2)(HIPAA)

AUTHORIZATIONFORTHE RELEASEOFMENTALHEALTHRECORDS PURSUANTTO45CFR164.508(a)(2)(HIPAA)

TO:

NameofMentalHealthcareProvider/Physician/Facility

Address(Street,City,State,ZipCode)

RE:PatientName:______

Date of Birth: ______Social Security Number: ____ --____--___

Address:______

I, ______, authorizeyoutoreleaseandfurnishto:

[INSERT DEFENSE COUNSEL]

and/orher/his/theirdesignated agent,[insert agent, if any]copiesoffullandcompleteprotected medicalandmentalhealthinformation,includingthefollowing:

ForuseintheIn Re Testosterone Therapy Replacement ProductsLiabilityLitigation,MDL2545. Tomyhealthcare provider: Thisauthorizationisforwardedbyattorneysfordefendant(s). Thisauthorizationpermitsyoutoreleasecopiesofrecordsyoumadeinconnectionwithexaminations,diagnosisandtreatmentofme,·it doesnotpermityou,nordoesitauthorizeyou,tospeaktoanyoneconcerningyourcareandtreatmentof me,unlessyoureceiveaseparateandadditionalauthorizationpermittingsuchdiscussion. Subjecttoall applicablelegalobjections,thisrestrictiondoesnotapplytodiscussingmymedicalhistory,care, treatment,diagnosis,prognosis,informationrevealedbyorintherecords,oranyothermatterbearingonmymedicalorphysicalconditionatadepositionortrial.

•Allpsychiatric,psychological orotherconfidentialrecordsrelatingtomyemotionalorother psychiatric/psychologicalconditionforthepurposeofreviewandevaluationinconnectionwitha legalclaim. Iexpressly requestthatthedesignatedrecordscustodianofallcoveredentitiesunderHIPAAidentifiedabovedisclosefullandcompleteprotectedmedicalandmentalinformation includingthefollowing:

oAllpsychiatric/psychologicalrecords,includinginpatient,outpatientandemergencyroom treatment,allclinicalcharts,reports,ordersheets,progressnotes,nurse's notes,clinic records,treatmentplans,admissionrecords,dischargesummaries,requestsforandreportsof consultations,documents,correspondence,testresults,statements, questionnaires/histories, recordsreceivedbyotherphysicians,pharmacyandprescriptionrecords,billingrecordsand recordsofbillingtothirdpartypayersandpaymentor denialofbenefits.

Thisprotectedhealthinformation isdisclosedforthefollowingpurposes: Thecurrentlypendinglitigationinvolvingthepersonnamedabove.

Thisauthorizationisgivenincompliancewith42CPR2.31,therestrictionsofwhichhavebeen specificallyconsideredandexpresslywaived.

Youareauthorizedtoreleasetheaboverecordstotherepresentativesofdefendantsnotedabovewho haveagreedtopayreasonablechargesmadebyyoutosupplycopiesofsuchrecords.

IacknowledgethatIhavetherighttorevokethisauthorizationbywrittennotificationtoyouattheabove referencedaddress. However,Iunderstandthatanyactionsalreadytakeninrelianceonthisauthorization cannotbereversed,andmyrevocationwillnotaffectthoseactions.

Iacknowledge thepotentialforinformationdisclosedpursuanttothisauthorizationtobesubjectto

redisclosurebytherecipientandnolongerbeprotectedunder45CPR164.508.

Iunderstandthatthe coveredentitytowhomthisauthorizationisdirectedmaynotconditiontreatment, payment,enrollmentoreligibility benefitsonwhetherornotIsigntheauthorization.

Iunderstandthatthenatureofthisauthorization istoauthorizethereleaseofmymentalhealthrecords.

Anotarizedsignatureisnotrequired. CFR164.508. Afacsimile,copyorphotocopyofthis Authorizationshallhavethesameforceasanoriginal. Unlessotherwiserevoked,thisauthorizationshall expireattheconclusionofmyinvolvementinthecaptionedlitigation.

Ihavereadtheaboveandauthorizethedisclosureoftheprotectedmentalhealthinformationas stated.

Print Name:______