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)