Authorization To Disclose Information (Medical)

Appendix XII-C (new) AUTHORIZATION TO RELEASE PRIVATE HEALTH CARE INFORMATION AND FOR VOLUNTARY INTERVIEW TO: __________________________ __________________________ __________________________ RE: _______________________ DOB: _______________________ SS#: _______________________ I hereby authorize you to disclose my protected health information to and to participate in a voluntary interview with: _________________________________________ _________________________________________ _________________________________________ In defending against the lawsuit I have filed against ___________________, the defendant is entitled to seek to interview witnesses with relevant information. Your participation in any such interview is entirely voluntary. You have the right to have my attorney present at the interview. You may disclose protected information reasonably related to the medical condition I have place in issue by my lawsuit. That condition relates to: _________________________________________ _________________________________________ This authorization may be revoked by me at any time, and expires 120 days from the date I execute the authorization as indicated below. If you have questions relating to the scope of this authorization, you may contact your own attorney or my attorney: __________________________________________ __________________________________________ __________________________________________ Patient signature: ___________________________________ Date: _____________ [Note: Form adopted as Appendix XII-C July 27, 2006 to be effective September 1, 2006.] American LegalNet, Inc. www.FormsWorkflow.com