Navigating the complexities of legal proceedings often involves a delicate balance between confidentiality and the necessity for disclosure, a balance that the Arons Authorizations form aims to manage with precision. Designed primarily for use within the realm of personal injury lawsuits, this form serves as a formal permission slip, allowing defense attorneys to directly interview the plaintiff's treating physicians about specific medical conditions related to the case. Its meticulous structure ensures that only relevant health information is shared, safeguarding the patient's privacy while providing essential insights into the lawsuit's medical aspects. A unique feature of the Arons Authorization form is its specificity: it limits discussion solely to conditions pertinent to the ongoing litigation, underscores the voluntary nature of physician participation, and outlines the conditions under which sensitive information about alcohol, drug treatment, mental health, and HIV-related data may be disclosed. Furthermore, it emphasizes the rights of the patient, including the capacity to revoke the authorization and the protection against unauthorized redisclosure, underscoring the patient's autonomy and the legal safeguards in place to protect personal health information in the context of legal defenses.
| Question | Answer |
|---|---|
| Form Name | Arons Authorizations Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | aron authorization, arons authorization, interview permitted pdf, arons authorization pdf |
AUTHORIZATION TO PERMIT INTERVIEW OF TREATING PHYSICIAN BY DEFENSE COUNSEL
TO:
Physician’s name and address
You are hereby authorized to discuss certain medical condition(s) involving:
with
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Patient’s name |
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who is an attorney |
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Defense Attorney’s Name and Address |
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representing |
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in a |
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Defendant’s name |
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Type of Lawsuit |
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brought by |
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against |
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Plaintiff(s) Name |
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Defendant(s) |
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The lawsuit is currently pending and is at
Stage of Proceeding
YOU ARE PERMITTED TO DISCUSS ONLY THE FOLLOWING MEDICAL CONDITIONS WHICH ARE THE SUBJECT MATTER OF THE AFOREMENTIONED LAWSUIT:
1.NOTHING CONTAINED HEREIN AUTHORIZES YOU TO DISCUSS ANYTHING ABOUT THIS PATIENT OTHER THAN THE
2.THE PURPOSE OF THIS INTERVIEW IS TO ASSIST THE DEFENDANT(S) IN THE DEFENSE OF THIS LAWSUIT BROUGHT BY THIS PATIENT. THIS AUTHORIZATION IS NOT AT THE REQUEST OF YOUR PATIENT.
3.YOUR WILLINGNESS TO PARTICIPATE IN THIS INTERVIEW IS ENTIRELY VOLUNTARY. YOU ARE FREE TO DECLINE THE REQUEST FOR SAID INTERVIEW.
4.You are permitted to disclose information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except
psychotherapy notes, and CONFIDENTIAL HIV RELATED INFORMATION only if specifically initialed below:
(Indicate by Initialing): |
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Alcohol/Drug Treatment; |
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Mental Health Information; |
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5.If I am authorizing the release of
6.I have the right to revoke this authorization at any time by writing to the health care provider listed. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
7.I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
8.Information disclosed under this authorization might be redisclosed by the recipient (except as noted in Item 5 above), and this redisclosure may no longer be protected by federal or state law.
9.If not the patient, name of person signing form:
10.Authority to sign on behalf of patient:
11.Date this authorization will expire:
Signature |
Date |