Authority To Release Medical And Or Hospital Records

AUTHORITY TO RELEASE MEDICAL AND/OR HOSPITAL RECORDS To: __________________________ Patient: _______________________ Address: _______________________________ Address: _______________________________ You are hereby authorized to furnish and release to my attorney, ____________________, ____________________________ (address, telephone no.)_______________. All information and records he requests concerning findings, treatment rendered, and opinions as to my condition, including records of any attempted suicide, abuse of drugs or alcohol, and pathological examination of tissue removed. Please do not disclose information to insurance adjusters or other persons without written authority from me (pursuant to confidential and privileged communications laws). All prior authorizations are hereby cancelled, and I waive any privilege I have to my said attorney. The foregoing authority shall continue in force until revoked by me in writing, but no longer than one year from the below date. This information is necessary for my said attorney to represent 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) ____Medical report (in duplicate) ____Complete hospital record ____Hospital record (without nurses/notes ____Abstract of hospital records ____Reports of all notes of surgical procedures _____First aid report only _____X-ray reports _____X-ray films _____Positive copies of X-ray films _____Laboratory reports _____Advise if any prior admissions or treatment Approximate date(s) service rendered __________________________________ __________________________________ _________________________20_______ Thank you, _____________________________ Attorney-at-Law _____________________________ _____________________________ American LegalNet, Inc. www.FormsWorkFlow.com