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Client Records Authorization - Georgia

Client Records Authorization Form. This is a Georgia form and can be used in Law Practice Management State Bar Of Georgia Statewide .
 Fillable pdf Last Modified 5/19/2005
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CLIENT RECORDS AUTHORIZATIONI hereby authorize the release and disclosure of the following documents , reports andrecords and copies thereof to my attorney, ______________________, or hisrepresentatives: 1. Any physicians records, hospital records, charts, x-rays, inform ation, opinionsconcerning examination, tests, diagnoses, treatment and prognoses concer ning my physicaland mental health; 2. Any police, investigative, insurance, and any other accident reports , records,statements, photographs, or other information concerning me;3. Any and all income and financial records, including payroll records, Federal and Stateincome tax returns, and Social Security detailed earnings records, for t he periods or yearsof ____ through _____; and 4. Federal, State or local agency records, files or information in any way concerning me.I revoke all prior authorizations and releases.Signed at ____________________________, Georgia this ________ day of___.___________________, _______________________________________________Client
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