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Authority To Release Medical And Or Hospital Records - Georgia
| Authority To Release Medical And Or Hospital Records Form. This is a Georgia form and can be used in Law Practice Management State Bar Of Georgia Statewide . |
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AUTHORITY TO RELEASE MEDICAL AND/OR HOSPITAL RECORDS To: Address: Patient: Address: Age: You are hereby authorized to furnish and release to my attorney, , , , all information and records he requestsconcerning findings, treatment rendered, and opinions as to my condition , including records ofany attempted suicide, abuse of drugs or alcohol, and pathological exami nation of tissueremoved. Please do not disclose information to insurance adjusters or o ther persons withoutwritten authority from me (pursuant to confidential and privileged comm unications laws). Allprior authorizations are hereby canceled, and I waive any privilege I ha ve to my said attorney.The foregoing authority shall continue in force until revoked by me in w riting, but no longerthan one year from the below date. This information is necessary for my said attorney torepresent me in regard to my injuries. ,20 X Patient (if minor, adult with authority to act; if patient deceased, legal representative) Witness Witness TO DOCTOR OR HOSPITAL RECORD LIBRARIAN: PLEASE READ THE UNDERSIGNED FOR RECORDS DESIRED. I respectfully request the following: Itemized bill for services (in duplicate) First aid report only Medical report (in duplicate) X-ray reports Complete hospital record X-ray films Hospital record (without nurses notes) Positive copies of X-ray films Abstract of hospital records Laboratory reports Reports of all notes of surgical procedures Advise if any prior admissions or treatmentPlease attach your invoice for any photostatic cost and send with reques t records to my office.Approximate date(s) service Thank you,rendered 20 Attorney at Law
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