General Authorization to Obtain Records

  • I hereby grant permission to Will & Will PLLC, And authorize any of its employees, agents or representatives to examine, inspect, copy or obtain a copy of any and all of the following in your possession and control, as specified below, to be used in my behalf, at my request, by my attorney. I realize that my attorney may disclose my information to a third party and that the third party may not be required to abide by this Authorization or applicable law governing the use and disclosure of my information.

    I am aware that this disclosure may or may not result in remuneration to the provider and that any information obtained through this authorization is CONFIDENTIAL INFORMATION which may also be LEGALLY PRIVILEGED and which is intended for the use of the claimant named above. This authorization will be in full force and effect whether it is an original or photocopy of the same and shall become effective and remain in effect for one year from its effective date unless revoked in writing by the undersigned prior to that date, except to the extent that action has already been taken.

  • I have the right to receive, and in fact have received a copy of this authorization. I also acknowledge that I have the right to revoke this authorization, should I choose to do so.

  • Date Format: MM slash DD slash YYYY

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