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Legal Aspects of Health Information Management by Marvins

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- 1 - AUTHORIZATION TO RELEASE LIFE INSURANCE DATA TO: ___________________________________________________________ RE: ___________________________________________________________ Please be advised that the law firm of _____________________________________________________, and each of them or someone acting on their behalf, are hereby authorized to inspect, obtain copies, make compilations or summaries of all documents and records in your possession or obtain information regarding any life insurance policies on which I am named insured, beneficiary and/or owner, which are maintained with or through you. The information is needed for the following purpose: Dissolution of marriage proceeding pending in ______________ County District Court. 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 (including claims and potential claims). This Authorization shall expire on ____________________. Upon fulfillment of the above- stated purpose(s), this consent shall automatically expire without my express revocation. A photocopy of this Authorization shall be treated in the same manner as an original. Dated: ________________________________________________________

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Legal and ethical Aspects of health information Management

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