Fill and Sign the Authorization Release Medical Form

STATUTORY AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO: ______________________ Re: ______________________ (Patient's Name) ______________________ Date of Birth: ______________________ Social Security No.: ______________________ This is your full and sufficient authorization, pursuant to Minn. Stat. §144.335, to communicate with and to release to attorney ______________________ , or his/her agents, all medical information (including but not limited to that which involves treatment for alcohol or drug abuse, and emotional problems) records, reports, notes and billing and financial statements maintained while I was a patient/client of yours on any date. This authorization specifically includes records prepared prior to the date of this authorization and records prepared after the date of this authorization during the pendency of this proceeding. I understand that I may revoke this consent in writing at any time. Upon the fulfillment of the above-stated purpose, this consent will automatically expire without my express revocation. A photocopy of this Authorization will be treated in the same manner as an original. Dated: ______________________ ______________________ I verify that the proceeding requiring this information is still pending and that information provided pursuant to this authorization will not be released for purposes not related to this proceeding. Firm _________________________ - 1 - By _________________________ _________________________ Printed Name _________________________ _________________________ _________________________ Address _________________________ Telephone Attorney for ______________ THIS AUTHORIZATION IS VALID FOR UP TO ______________ ( ______ ) DAYS FROM THE DATE OF EXPIRATION - 2 -