PHYSICIAN
RELEASE OF MEDICAL INFORMATION
TO
PATIENT'S ATTORNEYS
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)
