AUTHORIZATION FOR MEDICAL INFORMATION AND BILLS (CLIENT= S) ,

FORM 3.60

To:

Upon presentation of the original or any photocopy of this signed authorization, I authorize any medical professional, hospital or other medical care institution, pharmacy, governmental agency, dentist, rehabilitation or therapy service, insurance company, group policy holder, Medicare or employer to provide   with information concerning any condition or injuries of myself. I authorize the release of copies of bills regarding my treatment. I also allow to informally discuss my condition, treatment, medical history, or injuries with my physician. The address and telephone number of   is   .

This authorization is for all medical information without limitation as to type and includes, and is not limited to, x-rays, consultation reports, outside laboratory reports, chemical or drug dependency records, psychiatric records, psychotherapy notes, outpatient treatment records, medical correspondence, and all records showing medical treatment or information. This authorization expires 25 months from the date signed below. This authorization may be revoked by the undersigned by presenting a signed and dated written revocation to the person or entity described above and is effective from the date of such presentation. The revocation is not effective as to any medical information and bills provided by such person or entity in reliance upon this authorization.

Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by rules relating to the privacy of individually identifiable health information under 45 C.F.R. Part 164.

The purpose or need for disclosure of the records is for a legal investigation or litigation. I understand that my healthcare and my payment for my healthcare will not be affected if I do not sign this form.

A photocopy of this authorization is to be as effective as the original.

______________ are my attorneys. Please cooperate with them. Disclose no information to others, including insurance adjusters, without written authority from me.

Send   the bill for furnishing information copies, so they may promptly pay you on my behalf.

Date:

(Client= s Signature)

Name:  

Address:

Date of Birth: