Authorization to Obtain Medical Records and Billing Information

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Authorization to Obtain Medical Records and Billing Information for use in a legal proceeding. This authorization sets out the information to be provided and can be revoked at any time by the client.

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This Authorization to Obtain Medical Records and Billing Information will authorize an attorney to obtain a client's medical and billing information. This authorization contains the name of the client, medical provider who possesses the information and purposes for which the information can be used. It also spells out that the client may revoke the authorization at any time. A written Authorization to Obtain Medical Records and Billing Information is necessary in order for an attorney to obtain this needed information.

This Authorization to Obtain Medical Records and Billing Information contains:
  • Authorization/Entity: Entity to whom the authorization is given and the types of information to be provided;
  • Purpose: Sets out that the information is for use in connection with a legal claim or proceeding;
  • Revocation: This authorization can be revoked at any time by the client;
  • Signature: Client/Patient must sign and date this agreement in order for it to be effective.

Protect your rights and property by using our attorney-prepared forms.

This attorney-prepared packet contains:
  1. General Instructions
  2. Authorization to Obtain Medical Records and Billing Information
State Law Compliance: This form complies with the laws of all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
Number of Pages2
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28067
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
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