AUTHORIZATION TO RELEASE MEDICAL RECORDS
DATE:
FROM: Leslie S. Robinson
THE ROBINSON LAW FIRM
1510 E. Arlington Blvd.
P.O. Drawer 15
Greenville, NC 27835-0015
TO:
RE:
SS#
Date of Birth:
You are hereby authorized to furnish and release to my attorney, LESLIE S. ROBINSON, or any representative thereof, any and all past, present, or future medical or hospital records, x-rays or other items that may be requested relative to any hospitalization, institutionalization or treatment received by me, ___________________, in my lifetime. This authorization is intended to apply to physical as well as mental examinations, including specifically psychological, psychiatric, and other examinations regarding my mental abilities, functions, dysfunctions, etc. You are respectfully requested to cooperate with my attorney in supplying them with any documentation they may request. Should my attorney request a conference with you concerning any said treatment, injuries, or records, I hereby authorize, instruct and request you to freely discuss with them any and all information concerning my treatment, injuries or records which they may request from you. No other persons should be granted access to my records without a properly notarized authorization signed by me.
I expressly waive all medical privileges afforded the patient or myself under any and all provisions of federal, state or local laws, including specifically 42 Code of Federal Regulations, Part 2. Time is of the essence and under no circumstances are you to refuse to honor this authorization and release for any technical reason as it is my express intent to waive all technicalities so that any request made by my said attorneys can be honored forthwith.
A photocopy of this authorization shall be acceptable as the original. This authorization is valid for any past, present or future requests of my attorneys for such information for a period of sixty (60) days from the date of this authorization or until expressly revoked by me in writing.
This the ______ day of _______________, 20_______.
________________________________
AUTHORIZATION TO RELEASE MEDICAL RECORDS
Page -2-
______________________________________
STATE OF NORTH CAROLINA
COUNTY OF __________
Sworn to and subscribed before me
this the ______ day of ____________, 20________.
_____________________________________
Notary Public
My Commission Expires:________________
Return Requested Information to:
Leslie S. Robinson
THE ROBINSON LAW FIRM, P.A.
1510 E. Arlington Blvd.
Post Office Drawer 15
Greenville, NC 27858-0015
(252) 758-4100