[Caption. See § 3 of the Introduction in this manual.]
Order on Motion for Order to Obtain Protected Health Information
On [date] the Court considered [name of movant]’s Motion for Order to Obtain Protected Health Information of [name of patient].
The Court finds that the health information is relevant to the issues of this case.
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Select one of the following. |
IT IS ORDERED that [name] execute an Authorization for Release of Protected Health Information, in the form of the authorization attached as an exhibit to [name of movant]’s Motion for Order to Obtain Protected Health Information, authorizing [name and address of health-care provider] to disclose the protected health information of [name of patient] described below.
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Or |
IT IS ORDERED that [name and address of health-care provider] shall produce the protected health information of [name of patient] described below.
IT IS FURTHER ORDERED that the health information shall be produced on [date] at [time] at the offices of [name and address of movant’s attorney].
IT IS FURTHER ORDERED that all parties in this case, their counsel, the employees of their counsel, and their respective agents are prohibited from using or disclosing the health information of [name of patient] produced pursuant to this order for any purpose other than the litigation of this case.
IT IS FURTHER ORDERED that the health information (including all copies) produced pursuant to this order be either returned to [name of health-care provider] or destroyed at the end of the litigation pending before this Court.
The costs of production and copying shall be paid in the following manner: [specify manner of payment].
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Continue with the following. |
The following health information of [name of patient] is subject to this order:
Dates of health-care services provided: ________________________
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Select as applicable. |
¨ 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]
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Continue with the following. |
SIGNED on ________________________________.
JUDGE PRESIDING