RELEASE OF MEDICAL INFORMATION
_______________________________ (treating physician)
Name and Address :_____________________________________________
Security Number: ___________________________
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 _______________ (month & day),
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.
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.
authorization and waiver of privilege is extended not only to
_________________, my attorneys at law, but also to anyone in their employment.