This protected health information is disclosed to my attorney to aid in the recovery of damages resulting from a personal injury.
This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.
You are authorized to release the above records to the following representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:This authorization appoints BAUSCH LAW GROUP to represent patient.
a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
b. The information released in response to this authorization may be re-disclosed to other parties.
c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
d. I have a right to receive a copy of the authorization. I also have a right to receive a copy of my medical records obtained.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records request herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.