Fill and Sign the Summary of Nh Law Related to Health Nh Dhhs Form

AUTHORIZATION TO RELEASE CONFIDENTIAL RECORDS I, ________________________________, hereby authorize each and every physician; medical practitioner; hospital; clinic; dispensary or facility; provider of healt h care; insurance company; employer; educational institution; governmental agency, whether it be Federa l, State, or Local; to allow ____________________, Attorney at Law, and/or his employees, agents, copy service, legal representative to REVIEW, INSPECT , COPY and/or PHOTOCOPY any and all of the following in your possession or control pertaining to my child __________________________________: 1. X-Rays, films and reports; 2. Medical reports, records, charts, physician orders, laboratory records, autopsy reports; 3. Records related to accounts, billings and fees; and/or 4. Personnel, attendance, employment, payroll and wage records of my employer or schools. The above information is being obtained to assist in evaluating and/or prosecuting my claim for benefits or damages. I also authorize Plaintiff Attorney to request written m edical reports and to discuss my injuries with my health care providers. NOTE: This is a release for my attorney to obtain access to my records. This release is not a request for the information. If such information is actually requested, the request will be made separate from this release form. Dated: _______ day of _______________, 2001. Signed: _____________________________ Print Name: _________________________ Date of Birth: ________________________ Social Security No: ___________________