IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS ) ) ) Plaintiff, ) ) vs. ) ) THOMAS M. SMITH, ) ) Defendant. ) ______________________________) JOHN D. DOE,
AGREED ORDER FOR INSPECTION AND REPRODUCTION OF MEDICAL RECORDS AND PROTECTED HEALTH INFORMATION PURSUANT TO STATE AND FEDERAL LAW (HIPAA) AND NOTIFICATION OF WAIVER OF PHYSICIAN-PATIENT PRIVILEGE TO: All Hospitals, Clinics, Pharmacies, Physicians, Social Workers, Psychiatrists, Psychologists, Therapists, Government Agencies (State and Federal; All Other Medical Institutions, Practitioners and Health Care Providers, Past and Present NOW on this ______ day of _____________, 20__, this matter comes on before the Court on the application of the parties for an order directing all health care providers who have provided care and/or treatment to John D. Doe, to produce any and all health care information within their custody and/or control pertaining to said person. Plaintiff John D. Doe appears by and through his attorney [attorney name] and Defendant Thomas M. Smith, appears by and through his attorney [attorney name]. WHEREUPON, the court, after reviewing this files and records, hearing statements of counsel and being fully and duly advised in the premises finds: You are hereby authorized, directed, and ordered pursuant to the laws of Kansas and applicable federal law, including but no limited to the Health Insurance Portability and Accountability Act (HIPAA), to make available for examination and reproduction by the parties,
their counsel or their designee any and all medical records of any type or nature whatsoever and/or any protected health information within your care, custody, or control concerning [John D. Doe], Date of Birth:[ __________________________], Social Security Number: [ ________________________]. Medical documents and protected health information subject to this order include but are not limited to: [Insert any that apply under the circumstances of the case]: Every page of the entire medical chart cover to cover (including but not limited to all records pertaining to the examination, diagnosis, care and treatment of the patient, patient intake and registration forms; patient insurance and identification information; office narratives; progress notes; prescription orders; lab results; nurse and physician assistant notes; consultation reports; order sheets; handwritten notes; and, radiological and laboratory reports, itemized billing statements listing all charges, radiographic films, photographs and videotapes.) This order also includes all "Secondary Records," regardless of whether generated by you. Secondary Records include patient questionnaires; phone message slips; correspondence with patient; and all documents contained in the patient's office chart from other health care providers, insurance representative; attorneys or governmental agencies, including but not limited to: medical records as defined above and all correspondence and hospitalization records. · any and all records related to HIV testing, HIV status, AIDS and infectious or sexually transmitted diseases; The Plaintiff/patient has made a full and knowing waiver of the statutory privilege provided these records under K.S.A. 65-6002. · any and all records related to the diagnosis and treatment of mental illness or problems, or emotional condition; including any psychotherapy notes that are part of the medical record; The Plaintiff/patient has made a full and knowing waiver of the statutory privilege provided these records under K.S.A. 65-5602.
This Court specifically finds the above requested information necessary to this proceeding because the patient relies on the information for an element of the patient's claim or defense. [OR, if the patient is deceased: "the Plaintiff relies on the information of the patient's condition as an element of a claim or defense."] Unless specifically excluded by this Order, ALL medical records and protected health information in your possession regarding the person noted above shall be produced or made available for inspection. Said inspection and reproduction may be requested by any attorney of record herein as set forth below, and clerical fees and expenses as permitted under K.S.A. 65-4971 shall be paid by the attorney requesting such examination, reproduction or interview. You are further notified that, pursuant to state law and the rules of the 3rd Judicial District, counsel for the parties are hereby authorized to talk with [patient/decedent]'s treating physicians or other health care providers, without counsel for the other parties, including the plaintiff, being present or participating, provided the health care provider consents to the interview. This is based on the Court's finding that the plaintiff has made a claim for personal injuries, and in filing this lawsuit has and pursuant to Kansas law has therefore waived any privilege existing between the patient and health care provider as defined in K.S.A. 60-427. By virtue of filing this suit, the plaintiff is aware that this order has been entered and has been given the opportunity to object or has waived any objection. This Order complies with HIPAA federal standards for privacy of individually identifiable health information, 45 C.R.F. Parts 160 and 164 and Kansas Statute, K.S.A. 60-427, Physician-Patient Privilege. [Add if applicable:] ·This Order further allows the disclosure of all information regarding diagnosis of, treatment for and general status relating to HIV, AIDS or other infectious diseases pursuant to K.S.A. 65-6001 to 6010.
· This order further allows the disclosure of all information regarding diagnosis and treatment of mental and emotional condition pursuant to Kansas Statutes 65-5601 to 65-5603 (treatment facility privilege) and 74-5323 & 74-5372 (psychologist-patient privilege). This Order shall be effective throughout the pendency of this action. Dated this ____ day of ____________, 20___.
__________________________________ JUDGE OF THE DISTRICT COURT APPROVALS: