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PHYSICIAN RELEASE OF MEDICAL INFORMATION

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



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