AUTHORIZATION TO INSPECT AND COPY MEDICAL RECORDS TO: [insert name of health care provider] RE: [insert name of patient] This will authorize (the law firm of) ___________________________ or their representative to inspect and copy all office, medical and hospital records, reports1 and other medical documents in your possession and relating to injuries to the patient’ (insert body part(s) allegedly injured), and received by the patient s on or about (insert date of alleged injury). This authorization also includes medical records, reports and other medical documents in your possession which relate to any prior or subsequent complaints, injuries, illnesses or conditions involving the same parts of the body and the same or similar conditions as described below. This authorization includes but is not limited to records of all examinations, treatments and tests, including in-patient, out-patient and emergency room, whether for diagnostic or prognostic purposes, consultation, reports, correspondence, x-rays, photographs, videotapes, MRIs, and CT Scans [and post-mortem records]2 PROVIDED that the examinations, treatments and/or tests involve or relate to complaints, injuries, illnesses or conditions pertaining to the following alleged injury: [insert allegation from Petition which describes injured part(s) of body]. The health care provider is neither required nor prohibited by law from engaging in private conversations regarding the patient’ above-referenced care. s The decision to enter into any such conversation is that of the health care provider. However, any disclosure that exceeds the scope of this authorization may subject the health care provider to civil liability. This authorization remains in effect until the underlying claim is finally resolved. Therefore, you may receive a supplemental request for documents. Provided you have an original authorization allowing you to provide records to the party making the supplemental request, a written request for supplemental documents is sufficient, and no additional authorization is required. [The patient further requests that the health care provider supply complete copies of all documents produced pursuant to this authorization to patient’ s attorneys, ___________, at their expense.]3 1 As used in this authorization, the term “ report”does not include any document prepared in anticipation of litigation. 2 Insert if applicable. 3 If desired by Plaintiff’ counsel. s American LegalNet, Inc. www.FormsWorkFlow.com