This Letter and Authorization to Obtain Medical Records and Billing will effectively request a client's medical records and information about the client's billings. This letter contains the name of the client, his or her date of birth, Social Security number and the date the request was sent. Also enclosed with the letter is an Information Release Authorization previously signed by the client authorizing disclosure of the records. A written Letter and Authorization to Obtain Medical Records and Billing will ensure that you receive the necessary information in order to move your client's case forward.

This Letter and Authorization to Obtain Medical Records and Billing includes the following:

• Client Information: Sets forth the relevant information regarding the client, including full name and date of birth;
• Representation: Informs the provider that your office was retained to represent the client regarding a specific injury (such as automobile or on the job accident);
• Authorization: Encloses an Information Release Authorization signed by the client to ensure that the medical records are released.

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This attorney-prepared packet contains:

1. General Information
2. Letter and Authorization to Obtain Medical Records and Billing

State Law Compliance: This form complies with the laws of all states