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Sample Form: Medical Records Release
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One of the first steps in the process of assessing your legal claim is to review your medical records. Some personal injury lawyers have medical professionals on their staffs who assist in the records review process and then advise the attorneys on the medical aspects of the case. Other attorneys may seek the assistance of independent physicians outside of their office who are familiar with the types of injuries involved and who may even be called upon to testify if the case goes to trial. In any event, your attorney will need you to sign a release form like the one below so that your medical providers are authorized to provide a copy of your records to your lawyer.
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Patient's name _____________________________________________ Date of birth ____/____/____ Social Security Number ______-___-_______ Address ______________________________________________ Telephone number (____) ____-_______ Please release my medical records from: Name of provider __________________________________________ TO:
Please release all records, including but not limited to, progress notes, operative notes, laboratory test results, diagnostic tests, and x-rays. I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS AS PROVIDED ABOVE. _______________________________________ Date: ______________________________ |
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TotalInjury.com - How much is Your Personal Injury Case Worth? Personal Injury Tools.
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