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To: _______________________________ (treating physician)

of _________________________________ (hospital)


Patient’s Name and Address :_____________________________________________


Social Security Number: ___________________________


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 _______________ (month & day), ________ (year).


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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