MEDICAL AUTHORIZATION

class=Section2>

TO:

I, , hereby authorize you to furnish to my attorney, , or to any agents, designees or representatives, any and all records of any kind pertaining to me, including but not limited to, my medical history, medical or other services rendered, treatment, billings, and all such related records.

This authorization shall become effective immediately and shall remain in full force and effect as long as is necessary for my attorney to fulfill his obligations, said term to be defined by my attorney in his absolute discretion.

I understand that some restrictions for receipt of or release of medical information may apply to my attorney as to some medical or other facilities. I hereby direct that no further authorization other than is specifically indicated in this form be required and/or requested of my attorney.

I ALSO CONSENT TO THE RELEASE OF ANY AND ALL ALCOHOL AND/OR DRUG ABUSE OR PSYCHIATRIC TREATMENT RECORDS UNDER THE SAME CONDITIONS AS OUTLINED ABOVE. I UNDERSTAND THAT SUCH INFORMATION CANNOT BE RELEASED WITHOUT MY SPECIFIC CONSENT.

This consent is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, and the duration of this consent shall be no longer than is reasonably necessary to effectuate the purpose for which is given, i.e., through the final determination of the reasons stated above, including any appeal process, and then will expire without express revocation.

THE FEDERAL PRIVACY ACT AND OTHER APPLICABLE GOVERNMENTAL REGULATIONS HAVE INCREASED THE NEED FOR SECURITY IN THE TRANSFER OF PRIVILEGED COMMUNICATIONS. THE INFORMATION TO BE RELEASED WILL BE FROM RECORDS, THE CONFIDENTIALITY OF WHICH IS PROTECTED BY THOSE REGULATIONS, AND PROHIBITS ANYONE FROM MAKING ANY FURTHER DISCLOSURE OF SUCH INFORMATION WITHOUT SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS.

A PHOTOCOPY OF THIS SIGNED AUTHORIZATION SHALL BE DEEMED AS VALID AS AN ORIGINAL.

I have read the above and fully understand its content in its entirety, and have asked questions about anything that was not clear to me, and am satisfied with the answers I have received.

DATE: SOCIAL SECURITY NO.

DATE OF BIRTH:

SIGNATURE: