PHYSICIAN
RELEASE OF MEDICAL INFORMATION
TO
ATTORNEYS RETAINED BY PATIENT
To:
_______________________________ (Treating
Physician)
of
_________________________________ (Hospital)
Patient’s
Name and Address: _____________________________________________
Social
Security No: ___________________________
Birth
Date: ___________________
Please
be advised that I, ___________________________________________ (Name), have retained the firm of
___________________________________, attorneys at law, to represent me in a
claim for personal injuries and/or property damage which resulted from an
accident that occurred on __________ (Date).
You
are authorized to furnish to them any and all information they may request
concerning my injuries, including, but not limited to, photocopies of any
medical records and/or reports.
You
are further authorized and requested to discuss with them any history or
findings you have regarding me or my condition, and I expressly waive any right
I may have of privilege as your patient.
This
authorization and waiver of privilege is extended not only to
_________________, my attorneys at law, but also to anyone in their employment.
______________________________ ____________________
Signature
Date
