Authorization for Release of Information
Section A: Must be completed for all authorizations
I hereby authorize the use or disclosure of my individually identifiable health information and drivers license information as described below. I understand that this authorization is voluntary. I request that this information be released to my attorney, Marcus E. Hill.
Driver's Full Name:
State and Drivers License Number:
Date of Birth (mm/dd/yyyy):
Persons/Organizations receiving the information:
Marcus E. Hill
Attorney at Law
311 E. Main Street
Durham, NC 27701
Specify description of information (including dates):
Driving Record/Abstract
Section B: Must be completed for all authorizations.
The driver must read and initial the following statements:
I. I understand that this authorization will not expire until I revoke it. Initials: ______
II. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do so it will not have any affect on any actions taken before the revocation was received. Initials: ______
III. I request that the information requested be provided to my attorney promptly. Initials:_____
IV. I understand that I may see a copy of the information described on this form, with the exception of, if I ask for it, and that I get a copy of this form after I sign it. Initials:______
x________________________________________ _________________________
Signature of Driver Date
(Form MUST be completed before signing)
___________________ County
State of North Carolina
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he/she voluntarily signed the foregoing document for the purpose stated therein and in the capacity indicated _____________________________________, (name(s) of principal(s))
Date: _____________________ _________________________________________
Notary Public
My Commission Expires: ____________________
(Official Seal)