Form 6-21

Protected health information may be disclosed by a provider who receives a valid authorization as specified by 45 C.F.R. § 164.508 or in response to a court order as provided in 45 C.F.R. § 164.512(e)(1).

[Caption. See § 3 of the Introduction in 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 3 of the Texas Estates Code.

[Name of movant] seeks an order from the Court requiring [name] to execute an Autho­rization for Release of Protected Health Information for [name and address of health-care pro­vider] to produce certain protected health information of [name of patient], pursuant to title 45, section 164.508, of the Code of Federal Regulations. A copy of the release is attached as Exhibit [exhibit number/letter].

Alternatively, [name of movant] requests that the Court enter a qualified protective order, pursuant to title 45, section 164.512(e), 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¨   Prescription and medicine records¨   Test results¨   Consultations¨   Correspondence¨   Hospital records¨   Nurses’ notes¨   Billing 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 ObtainProtected Health Information.

   
[Name]
Attorney for [name of movant]
State Bar No.:
[E-mail address]
[Address]
[Telephone]
[Telecopier]

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]

Notice of Hearing

The above motion is set for hearing on ____________________ at __________ __.m. in [designation and location of court].

SIGNED on ________________________________.

   
Judge or Clerk

Certificate of Service

I certify that a true copy of the above was served on each attorney of record or party in accordance with the Texas Rules of Civil Procedure on [date].

   
[Name]
Attorney for [name of movant]