| RE: | Patient: |  |
_____________________________________ |
|
Date of Accident: | |
_____________________________________ |
|
Social Security #: | |
_____________________________________ |
To Whom it May Concern:
This will introduce the undersigned attorney as my representative with reference to the above-entitled accident.
This authorizes the physicians, hospital, and all medical attendants to furnish full and complete medical reports and information here requested by Ogletree Law Firm, L.L.P., or to any representative, attorney, investigator of said firm or other associated law firm, and especially any and all medical reports concerning injuries received as the result of an accident which occurred on or about the date above.
This authorization also includes permission to copy, view, or photograph all of the hospital notes, records and information, including but not limited to, laboratory tests and x-rays, for the receipt of any and all information you have concerning my physical and mental condition, including histories, examinations, tests, treatment, consultations and opinions and any and all other information available concerning this particular case.
DATED this _______ day of __________________________, 200____.
| _____________________________ | |
_____________________________ |
| Signature of Client/Patient | |
Printed Name of Client/Patient |