AUTHORIZATION TO RELEASE INFORMATION & RECORDS
I. What is Being Released: All Information & Records
I/we hereby authorize YOUR NAME, and/or his representative, to review, inspect, have, obtain, copy and receive all information, oral and documentary, including all notes, charts, records, reports, bills, statements, letters, pictures, recordings, and all other documents, depictions, electronic media, and writings , in every form and of every nature, in accord with the accompanying request.
This includes, but is not limited to, financial, credit, legal, police, health, medical, dental, SSA, SDI, insurance, VA, DMV, military, government, employment, education/school, and confidential records from any/all sources whatsoever.
II. Specific HIPPA Requirements
This authorization fully complies with the Health Insurance Privacy and Portability Act (HIPPA). The information and records sought by this authorization and the accompanying request will be used for purposes of my auto collision claim/litigation and preparation therefor (and as may be further explained in the accompanying request). This authorization shall be valid for a period of 90-days unless sooner revoked in writing by me, which I understand I have the option of doing. I have a copy of this authorization. I understand that once the information and records are released it is possible that they will be re-released and not kept confidential, however, no re-release should occur without my consent.
III. Copies Valid; Facsimile Signature Valid; All Forms of Communication Authorized
A copy of this authorization, including one bearing an electronic or facsimile signature, shall be as valid as the original. All methods of communication, including but not limited to facsimile and e-mail, are hereby authorized.
IV. Contact Person for Questions or Information
Please contact me if you should have any questions or concerns.
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