Form 5-33

NOTICE: THIS DOCUMENT
CONTAINS SENSITIVE DATA

[Caption. See § 3 of the Introduction in volume 1 of this manual.]

Motion for Order to Obtain Protected Health Information

This Motion for Order to Obtain Protected Health Information of [name of patient] is brought by [name of movant], who shows in support:

1.This is a case arising under [title 1/title 2/title 5] of the Texas Family Code.

[Name of movant] requests that the Court enter a qualified protective order, pursuant to section 164.512(e) of title 45 of the Code of Federal Regulations, addressing the rights and protections that apply to the protected health information pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). [Name of movant] requests that the qual­ified protective order provide that the requested health information protected by HIPAA be produced by [name and address of health-care provider] and further provide that the informa­tion is to be used only in connection with this litigation and that the parties to this matter, their counsel, the employees of their counsel, and their respective agents are prohibited from using or disclosing health information protected by HIPAA for any purpose other than in connection with this litigation. [Name of movant] further requests that the qualified protective order require the return of health information protected by HIPAA to [name of health-care provider] or the destruction of that information (including all copies) at the end of the litigation.

2.The following protected health information of [name of patient] is sought:

Dates of health-care services provided:

Progress notes

Laboratory reports

Operative reports

Discharge summary

Radiology reports

Consultation reports

X-ray or other images

Photographs/videotapes

Test results

Consultations

Correspondence

Hospital records

Entire health records in the possession of health-care provider

Other [specify]:

3.The protected health information of [name of patient] is relevant and necessary in this suit because [set forth reasons].

[Name of movant] prays that the Court grant this Motion for Order to Obtain
Protected Health Information.

   
[Name]
Attorney for [name of movant]
State Bar No.:
[Email address]
[Address]
[Telephone]
[Fax]

Certificate of Conference

I certify that a reasonable effort has been made to resolve the discovery dispute without the necessity of court intervention and has failed.

   
[Name]
Attorney for [name of movant]