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Authority To Release Medical And Or Hospital Records Form. This is a Georgia form and can be use in State Bar Of Georgia Statewide.
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Tags: Authority To Release Medical And Or Hospital Records, Georgia Statewide, State Bar Of Georgia
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
AUTHORITY TO RELEASE
:
Calendar No.
MEDICAL AND/OR HOSPITAL RECORDS
To:
Plaintiff(s)
-against-
Patient:
:
JUDICIAL SUBPOENA
Address:
:
Address:
Age:
:
You are hereby authorized to furnish and release to my attorney,
,
:
,
, all information and records he requests
concerning findings, treatment rendered, and opinions as to my condition, including records of
Defendant(s)
:
. .any .attempted. suicide, .abuse .of .drugs . . .alcohol,. and. pathological examination of tissue
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . or . . . . . . . . . . . . .
removed. Please do not disclose information to insurance adjusters or other persons without
written authority from me (pursuant to confidential and privileged communications laws). All
prior authorizations are hereby canceled, and I waive any privilege I have to my said attorney.
THE PEOPLE OF THE STATE OF NEW YORK until revoked by me in writing, but no longer
The foregoing authority shall continue in force
than one year from the below date. This information is necessary for my said attorney to
TO
represent me in regard to my injuries.
,20
GREETINGS:
X
Patient (if minor, adult with authority to act;
if patient deceased, legal representative)
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
Witness
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Witness
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
TO DOCTOR OR HOSPITAL RECORD LIBRARIAN: PLEASE READ $50 UNDERSIGNED
the party on whose behalf this subpoena was issued for a maximum penalty ofTHE and all damages sustained as a
FOR RECORDS to comply.
result of your failure DESIRED.
I respectfully request the following:
Witness, Honorable
Court in Itemized bill for services day duplicate)
County,
, 20
(in of
Medical report (in duplicate)
Complete hospital record
Hospital record (without nurse’s notes)
Abstract of hospital records
Reports of all notes of surgical procedures
, one of the Justices of the
First aid report only
X-ray reports
X-ray films
Positive copies name below)
(Attorney must sign above and typeof X-ray films
Laboratory reports
Advise if any prior
admissions or treatment
Attorney(s) for
Please attach your invoice for any photostatic cost and send with request records to my office.
Approximate date(s) service
rendered
Thank you,
Office and P.O. Address
20
Telephone Attorney at Law
No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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